CHIMA NCE Data & HER Exam 2026
Questions and Answers
An organization's legal health record definition must identify the following
regarding individually identifiable data:
a. Sources
b. Medium
c. Location
d. All of the above - Correct Answer -d
It is best practice to establish a ____ when defining the legal health record.
a. Policy
b. Master patient index
c. Health record matrix
d. Both a and c - Correct Answer -d
The legal health record can only be comprised of documentation that physically
exists in an electronic system.
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,True/False - Correct Answer -False
Which function is the first step in the creation of a patient's medical record and
initiates the flow of patient information within the EHR?
a. Analysis
b. Patient registration
c. Scheduling
d. Coding - Correct Answer -b
Which of the following processes includes deficiency analysis and chart
completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - Correct Answer -d
Malpractice cases generally fall into the category of _____.
a. Negligence torts
b. Intentional torts
c. Fraud cases
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, d. Criminal cases - Correct Answer -a
In a negligence case, a physician will be held to a standard of providing care that
reflects what is called _____ care.
a. Minimal
b. Optimal
c. Maximum
d. Reasonable - Correct Answer -d
A physician who fails to treat a patient who is brought to him or her for care is
guilty of _____.
a. Malfeasance
b. Misfeasance
c. Nonfeasance
d. Malpractice - Correct Answer -c
A physician who performs a surgical procedure without patient consent may be
prosecuted for _____.
a. Assault
b. Battery
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Questions and Answers
An organization's legal health record definition must identify the following
regarding individually identifiable data:
a. Sources
b. Medium
c. Location
d. All of the above - Correct Answer -d
It is best practice to establish a ____ when defining the legal health record.
a. Policy
b. Master patient index
c. Health record matrix
d. Both a and c - Correct Answer -d
The legal health record can only be comprised of documentation that physically
exists in an electronic system.
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,True/False - Correct Answer -False
Which function is the first step in the creation of a patient's medical record and
initiates the flow of patient information within the EHR?
a. Analysis
b. Patient registration
c. Scheduling
d. Coding - Correct Answer -b
Which of the following processes includes deficiency analysis and chart
completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - Correct Answer -d
Malpractice cases generally fall into the category of _____.
a. Negligence torts
b. Intentional torts
c. Fraud cases
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
, d. Criminal cases - Correct Answer -a
In a negligence case, a physician will be held to a standard of providing care that
reflects what is called _____ care.
a. Minimal
b. Optimal
c. Maximum
d. Reasonable - Correct Answer -d
A physician who fails to treat a patient who is brought to him or her for care is
guilty of _____.
a. Malfeasance
b. Misfeasance
c. Nonfeasance
d. Malpractice - Correct Answer -c
A physician who performs a surgical procedure without patient consent may be
prosecuted for _____.
a. Assault
b. Battery
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
