AHIMA RHIA FINAL EXAM QUESTIONS
AND ANSWERS GRADED A+ ASSURED
SUCCESS NEW UPDATE 2025/2026, Exams
of Nursing
The act of granting approval to a healthcare organization based on whether the organization has
met a set of voluntary standards is called:
a. Accreditation
b. Licensure
c. Acceptance
d. Approval a. Accreditation
Which specialized type of progress note provides healthcare professionals impressions of
patient problems with detailed treatment action steps?
a. Flow record
b. Vital signs record
c. Care plan
d. Surgical note c. Care plan
The data set designed to organize data about public health issues to inform purchasers and
consumers about the performance of healthcare plans is:
a. UHDDS
b. DEEDS
c. MDS
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,d. HEDIS d. HEDIS
Which of the following is not a true statement about a hybrid health record system?
a. Development of processes for both manual and computer processes is a challenge.
b. Creation of a definition of what constitutes a health record in manual and electronic format
must be developed.
c. Version control is easy to implement.
d. Security safeguards must be developed for both paper and electronic processes. c.
Version control is easy to implement.
Which type of health record contains information about the means by which the patient arrived
at the healthcare setting and documentation of care provided to stabilize the patient?
a. Ambulatory care
b. Emergency care
c. Long-term care
d. Rehabilitative care b. Emergency care
Ensuring data are not altered during transmission across a network or during storage is called:
a. Media control
b. Audit controls
c. Mitigation
d. Integrity d. Integrity
OASIS-C data are used to assess the ________ of home health services.
a. Core measure
b. Financial performance
c. Outcome
2|Page
,d. Utilization c. Outcome
The following is documented in an acute-care record: "HEENT: Reveals the tympanic
membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral
chest sounds." In which of the following would this documentation appear?
a. Medical history
b. Pathology report
c. Operation report
d. Physical examination d. Physical examination
Which of the following is considered a secondary data source?
a. Urinalysis laboratory report
b. Cancer registry
c. Pathology report
d. Patient problem list b. Cancer registry
Why should the copy and paste function not be used in the electronic health record?
a. The content may contain outdated information
b. Joint Commission standards prevent this practice
c. This feature is never found in the electronic health record
d. Medicare has a regulation against this practice a. The content may contain outdated
information
How long should the MPI be retained?
a. Permanently
b. 25 years
c. 50 years
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, d. 10 years a. Permanently
An RAI/MDS and care plan are found in records of patients in what setting?
a. Home healthcare
b. Long-term care
c. Behavioral healthcare
d. Rehabilitative care b. Long-term care
Which of the following contains the physician's findings based on an examination of the
patient?
a. Physical exam
b. Discharge summary
c. Medical history
d. Patient instructions a. Physical exam contains the findings
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood
pressure adequately controlled." In which part of a problem-oriented health record progress
note would this be written?
a. Assessment
b. Objective
c. Plan
d. Subjective a. Assessment
Which of the following is not a guideline for maintaining integrity in the health record?
a. Specifying consequences for the falsification of information
b. Requiring periodic training covering the falsification of information and information security
c. Prohibiting the entry of false information into any of the organizations' records
4|Page
AND ANSWERS GRADED A+ ASSURED
SUCCESS NEW UPDATE 2025/2026, Exams
of Nursing
The act of granting approval to a healthcare organization based on whether the organization has
met a set of voluntary standards is called:
a. Accreditation
b. Licensure
c. Acceptance
d. Approval a. Accreditation
Which specialized type of progress note provides healthcare professionals impressions of
patient problems with detailed treatment action steps?
a. Flow record
b. Vital signs record
c. Care plan
d. Surgical note c. Care plan
The data set designed to organize data about public health issues to inform purchasers and
consumers about the performance of healthcare plans is:
a. UHDDS
b. DEEDS
c. MDS
1|Page
,d. HEDIS d. HEDIS
Which of the following is not a true statement about a hybrid health record system?
a. Development of processes for both manual and computer processes is a challenge.
b. Creation of a definition of what constitutes a health record in manual and electronic format
must be developed.
c. Version control is easy to implement.
d. Security safeguards must be developed for both paper and electronic processes. c.
Version control is easy to implement.
Which type of health record contains information about the means by which the patient arrived
at the healthcare setting and documentation of care provided to stabilize the patient?
a. Ambulatory care
b. Emergency care
c. Long-term care
d. Rehabilitative care b. Emergency care
Ensuring data are not altered during transmission across a network or during storage is called:
a. Media control
b. Audit controls
c. Mitigation
d. Integrity d. Integrity
OASIS-C data are used to assess the ________ of home health services.
a. Core measure
b. Financial performance
c. Outcome
2|Page
,d. Utilization c. Outcome
The following is documented in an acute-care record: "HEENT: Reveals the tympanic
membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral
chest sounds." In which of the following would this documentation appear?
a. Medical history
b. Pathology report
c. Operation report
d. Physical examination d. Physical examination
Which of the following is considered a secondary data source?
a. Urinalysis laboratory report
b. Cancer registry
c. Pathology report
d. Patient problem list b. Cancer registry
Why should the copy and paste function not be used in the electronic health record?
a. The content may contain outdated information
b. Joint Commission standards prevent this practice
c. This feature is never found in the electronic health record
d. Medicare has a regulation against this practice a. The content may contain outdated
information
How long should the MPI be retained?
a. Permanently
b. 25 years
c. 50 years
3|Page
, d. 10 years a. Permanently
An RAI/MDS and care plan are found in records of patients in what setting?
a. Home healthcare
b. Long-term care
c. Behavioral healthcare
d. Rehabilitative care b. Long-term care
Which of the following contains the physician's findings based on an examination of the
patient?
a. Physical exam
b. Discharge summary
c. Medical history
d. Patient instructions a. Physical exam contains the findings
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood
pressure adequately controlled." In which part of a problem-oriented health record progress
note would this be written?
a. Assessment
b. Objective
c. Plan
d. Subjective a. Assessment
Which of the following is not a guideline for maintaining integrity in the health record?
a. Specifying consequences for the falsification of information
b. Requiring periodic training covering the falsification of information and information security
c. Prohibiting the entry of false information into any of the organizations' records
4|Page
