HIM Test Questions With Complete
Solutions58
Are non HIM members part of CHIMA board? - ANSWERS -Yes
CCHIM is responsible for (select all that apply: A. establishes the learning outcomes for HIM
programs, B identifies the standards of practice for entry level HIMs C. Creates and manages the
national certification exam) - ANSWERS -A, B and C
T or F: All entries in a health record whether paper or electronic need to be authenticated? -
ANSWERS -True
A newborn's record is filed with its mothers? - ANSWERS -No
T or F: Abbreviations are never allowed in a health record - ANSWERS -False
T or F: Specificity means that data needs to meet needs for clinical care only - ANSWERS -False
T or F: Prior to elective surgery a patient will sign a Consent for Release of Information -
ANSWERS -False
What is not a core competency of HIM Professionals (Biomedical science, technology,
management, access and privacy, health information analysis) - ANSWERS -Technology
,What are some typical elements of qualitative record analysis - ANSWERS -Diagnosis
inconsistencies, inconsistencies in identification (name of patient, DOB), time or location gaps,
use of non approved abbreviations
What occurs after qualitative and quantitative record analysis is complete? - ANSWERS -Coding
and abstracting
What is the primary purpose of a health record? - ANSWERS -To support the continuity of care
Secondary uses of the health record? - ANSWERS -Facilitate clinical decision making, funding,
education, research, operational management, legislation, support quality of care
Qualitative analysis is an important tool to ensure data quality. It evaluates: potential risk
events, adverse drug reactions, quality of documentation, quality of care through use of
established criteria. - ANSWERS -Quality of documentation
T or F: While doing a final check on a paper record an HIM notices a lab report is missing, once
printed and added to the record, it can then be filed. - ANSWERS -False- further analysis may be
needed as well as coding and abstracting
Discharge summary documentation must include: A. Detailed history of patient, B discharge
order, C. significant findings during hospitalization. D. A and C, E. All of the above - ANSWERS -C.
Significant findings during hospitalization
T or F: Redacting an entry in a record means deleting an error. - ANSWERS -False
T or F: If a patient presents their provincial health card at registration, there is no need to search
the MPI - ANSWERS -False
,Where would you expect to find this entry in a record: The patient was admitted to the medical
unit. He was started on Levaquin 500mg and then later reduced to 250mg daily. The patient was
hydrated with IV fluids. Cardiac enzymes were done 2 days. The chest pain resolved; ECG was
unchanged. Patient will be followed as an outpatient. - ANSWERS -Discharge summary
T or F: The chart order in a paper record is determined by a Health Record Committee -
ANSWERS -True
T or F: A delinquent record is the same as a deficient record. - ANSWERS -False
What is the key principle of the ADT? - ANSWERS -Collect once, use many
T or F: Verifying that a key document of a record is included and authenticated is a key step in
qualitative analysis? - ANSWERS -False. Quantitative analysis
T or F: The unintentional mis-identification of an individual is identity theft? - ANSWERS -False
Someone registers at a desk and the clerk finds 2 entries in the MPI this is an example of a: -
ANSWERS -Duplicate
Accurate client identification requires: A Clearly defined data elements B. Organizational policies
and procedures that are audited and enforced C. Rigorous staff training D. Standards for data
recording E. All of the above - ANSWERS -E. All of the above.
Advantages of concurrent coding include. A. Identifications of conditions that might have been
overlooked. B. More timely coding C. Faster qualitative and quantitative analysis. D. All of the
above - ANSWERS -D. All of the above.
What is the framework that facilitates communication between providers? - ANSWERS -
Nomenclature and terminologies
, Who manages SNOMED-CT - ANSWERS -IHTSDO (International Health Terminology Standards
Development Organization)
Who manages ICD in Canada? - ANSWERS -CIHI
T or F: DSM-IV and CCI share codes - ANSWERS -False
T or F: DSM-IV and ICD share codes - ANSWERS -True
What is the terminology of the EHR? - ANSWERS -SNOMED-CT
Coding is based on whose documentation? - ANSWERS -Physician's
Does the coder assign CMG or level of complexity? - ANSWERS -No
How many levels of complexity can there be in each CMG - ANSWERS -4
Case Mix Groups (CMG) are used for what type of data? - ANSWERS -Inpatient
What are Major Clinical Categories related to? - ANSWERS -Case mix groups- each major
diagnosis has a major clinical category and then within that are the cmg
What are three primary uses of case mix groups? - ANSWERS -Utilization management, planning
and budgeting, funding
T or F: The RIW for a case can change from year to year? - ANSWERS -True
Solutions58
Are non HIM members part of CHIMA board? - ANSWERS -Yes
CCHIM is responsible for (select all that apply: A. establishes the learning outcomes for HIM
programs, B identifies the standards of practice for entry level HIMs C. Creates and manages the
national certification exam) - ANSWERS -A, B and C
T or F: All entries in a health record whether paper or electronic need to be authenticated? -
ANSWERS -True
A newborn's record is filed with its mothers? - ANSWERS -No
T or F: Abbreviations are never allowed in a health record - ANSWERS -False
T or F: Specificity means that data needs to meet needs for clinical care only - ANSWERS -False
T or F: Prior to elective surgery a patient will sign a Consent for Release of Information -
ANSWERS -False
What is not a core competency of HIM Professionals (Biomedical science, technology,
management, access and privacy, health information analysis) - ANSWERS -Technology
,What are some typical elements of qualitative record analysis - ANSWERS -Diagnosis
inconsistencies, inconsistencies in identification (name of patient, DOB), time or location gaps,
use of non approved abbreviations
What occurs after qualitative and quantitative record analysis is complete? - ANSWERS -Coding
and abstracting
What is the primary purpose of a health record? - ANSWERS -To support the continuity of care
Secondary uses of the health record? - ANSWERS -Facilitate clinical decision making, funding,
education, research, operational management, legislation, support quality of care
Qualitative analysis is an important tool to ensure data quality. It evaluates: potential risk
events, adverse drug reactions, quality of documentation, quality of care through use of
established criteria. - ANSWERS -Quality of documentation
T or F: While doing a final check on a paper record an HIM notices a lab report is missing, once
printed and added to the record, it can then be filed. - ANSWERS -False- further analysis may be
needed as well as coding and abstracting
Discharge summary documentation must include: A. Detailed history of patient, B discharge
order, C. significant findings during hospitalization. D. A and C, E. All of the above - ANSWERS -C.
Significant findings during hospitalization
T or F: Redacting an entry in a record means deleting an error. - ANSWERS -False
T or F: If a patient presents their provincial health card at registration, there is no need to search
the MPI - ANSWERS -False
,Where would you expect to find this entry in a record: The patient was admitted to the medical
unit. He was started on Levaquin 500mg and then later reduced to 250mg daily. The patient was
hydrated with IV fluids. Cardiac enzymes were done 2 days. The chest pain resolved; ECG was
unchanged. Patient will be followed as an outpatient. - ANSWERS -Discharge summary
T or F: The chart order in a paper record is determined by a Health Record Committee -
ANSWERS -True
T or F: A delinquent record is the same as a deficient record. - ANSWERS -False
What is the key principle of the ADT? - ANSWERS -Collect once, use many
T or F: Verifying that a key document of a record is included and authenticated is a key step in
qualitative analysis? - ANSWERS -False. Quantitative analysis
T or F: The unintentional mis-identification of an individual is identity theft? - ANSWERS -False
Someone registers at a desk and the clerk finds 2 entries in the MPI this is an example of a: -
ANSWERS -Duplicate
Accurate client identification requires: A Clearly defined data elements B. Organizational policies
and procedures that are audited and enforced C. Rigorous staff training D. Standards for data
recording E. All of the above - ANSWERS -E. All of the above.
Advantages of concurrent coding include. A. Identifications of conditions that might have been
overlooked. B. More timely coding C. Faster qualitative and quantitative analysis. D. All of the
above - ANSWERS -D. All of the above.
What is the framework that facilitates communication between providers? - ANSWERS -
Nomenclature and terminologies
, Who manages SNOMED-CT - ANSWERS -IHTSDO (International Health Terminology Standards
Development Organization)
Who manages ICD in Canada? - ANSWERS -CIHI
T or F: DSM-IV and CCI share codes - ANSWERS -False
T or F: DSM-IV and ICD share codes - ANSWERS -True
What is the terminology of the EHR? - ANSWERS -SNOMED-CT
Coding is based on whose documentation? - ANSWERS -Physician's
Does the coder assign CMG or level of complexity? - ANSWERS -No
How many levels of complexity can there be in each CMG - ANSWERS -4
Case Mix Groups (CMG) are used for what type of data? - ANSWERS -Inpatient
What are Major Clinical Categories related to? - ANSWERS -Case mix groups- each major
diagnosis has a major clinical category and then within that are the cmg
What are three primary uses of case mix groups? - ANSWERS -Utilization management, planning
and budgeting, funding
T or F: The RIW for a case can change from year to year? - ANSWERS -True
