Health Information Management Review Questions
Course Introduction
Health Information Management explores the principles and practices involved in acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. Students will learn about the management of healthcare data, the structure and content of health records, health information technologies, privacy and security standards, legal and regulatory issues, and the use of electronic health records (EHRs) to support clinical and business decision-making. The course emphasizes the role of health information professionals in ensuring data accuracy, accessibility, and confidentiality within healthcare systems.
Recommended Textbook Health Information Technology 3rd Edition by Nadinia A. Davis
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Page 2
Chapter 1: Health Care Delivery Systems
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Sample Questions
Q1) Which health care professionals are responsible for orders that create the treatment plan?
A) Nurses
B) Physicians
C) Physical Therapists
D) Medical Assistants
Answer: B
Q2) Nonprofit health care facilities have the following characteristics EXCEPT:
A) Surplus income belongs to shareholders
B) Have a board of directors
C) All income beyond net income is used for charitable purposes
D) Receive federal tax breaks
Answer: A
Q3) Medicare is administered by:
A) FDA
B) CMS
C) Individual states
D) NCQA
Answer: B
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Page 3
Chapter 2: Collecting Health Care Data
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Q1) Your facility is using a paper-based record. The HIM department has decided to switch from an integrated record to a completely source-oriented record, postdischarge. You are responsible for training the staff members who assemble the records into the correct order. Which of the following must exist in order to implement this change?
A) All documentation must be changed to reflect the new order.
B) Except for physician's orders, physicians and nurses cannot document on the same page.
C) Nothing has to change; the way the clinicians document information is irrelevant to the chart order.
D) Physicians and nurses must document on the same page. Answer: B
Q2) Which of the following is NOT a benefit of a problem list?
A) Reduces the amount of documentation in the record
B) Facilitates management of the patient's care
C) Improves communication among caregivers
D) Creates an index to the patient's record
Answer: A
Q3) A collection or series of related characters is a ________. Answer: field
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Chapter 3: Electronic Health Records
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Sample Questions
Q1) Why is indexing an EHR important?
Answer: Indexing identifies the report by type and organizes the reports for easier retrieval when needed. It is similar to the plastic tab separators used in the paper records as it electronically divides the various sections and indicates in which section the information belongs. Indexing ensures that the EHR is organized and is able to retrieve patient files quickly.
Q2) How can an EHR system improve patient care? List at least three ways.
Answer: 1. Availability of information--more health care professionals can access patient records than with just paper health records.
2. Speed--with a click of a button, a physician can send an order that will prompt allied health professionals to action to fill the order.
3. Accuracy--the EHR systems has checks to ensure that the right medication is being administered to the correct patient.
4. Protection--EHR systems have password protection and encryption to prevent unauthorized access to patient records.
5. Alerts--drug interactions and patient allergies will always be present when caring for the patient to ensure that there are fewer errors.
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Chapter 4: Acute Care Records
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Q1) Which of the following would NOT be found on an admission record or face sheet?
A) admitting diagnosis
B) patient name
C) nursing progress notes
D) attending physician
Q2) In urgent situations, a physician's office may call a facility in advance to order an admission. This is called a ____________.
Q3) In caring for a patient, an attending physician may request a(n) ___________ from another physician or health care professional who specializes in the patient's problem.
Q4) __________ is the care provided through the use of mobile technology that allows care providers to view and consult patients from satellite locations.
Q5) There may be a(n) ______________ on the patient's wristband, readable by machine, which connects the patient to his or her medical record.
Q6) What are essential elements in the operative report? List at least five.
Q7) In a patient's history, the reason the patient presented for evaluation and treatment is called the_________________ complaint.
Q8) Name and describe the four scenarios that inpatient admissions correspond to.
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Chapter 5: Health Information Management Processing
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Q1) The data quality characteristic of data being present or existing in its entirety is
Q2) All of the following are steps in postdischarge processing EXCEPT:
A) Coding
B) Abstracting
C) Chart retrieval
D) Concurrent analysis
Q3) The postdischarge process begins with which of the following steps:
A) Assembling the patient chart
B) Analyzing the patient chart for deficiencies
C) Reviewing the discharge register
D) Requesting the physician's signature on deficient forms
Q4) Quantitative analysis is usually performed by:
A) An allied health professional
B) A nurse case manager
C) An HIM professional
D) A unit care nurse
Q5) ___________ procedures govern the storage of records, including duration, location, security, and access.
Q6) Is a computer-based record completely paperless? Why or why not?
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Chapter 6: Code Sets
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Q1) How does case mix analysis help health care providers plan for the future?
Q2) __________ is the assignment of alphanumerical values to a word, phrase, or other nonnumerical expression. In health care, coding is the assignment of numerical values to diagnosis and procedure descriptions.
Q3) A code set that is established by HIPAA guidelines used in electronic data transfer to ensure that the information transmitted is complete, private, and secure is known as a ___________.
Q4) The fifth character of an ICD-10-PCS code indicates which of the following?
A) The procedure was on the upper arm.
B) An endoscopy device was used.
C) The procedure was performed on the gastrointestinal body system.
D) The approach was through the natural opening.
Q5) An example of a CDT code is:
A) C1715
B) D5410
C) I20
D) 43251
Q6) Name the two levels of HCPCS.
Q7) In the ICD-O codes set, ____________ codes and _____________ codes are found.
Page 8
Q8) What does SNOMED-CT stand for?
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Page 9
Chapter 7: Reimbursement
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Q1) The systematic collection of specific charges for services rendered to a patient is called ___________.
Q2) The department in a hospital that is primarily responsible for submitting bills or claims for reimbursement is:
A) Health information management
B) Utilization review
C) Patient registration
D) Patient accounting
Q3) The federal law that established Medicare PPS is __________.
Q4) Health care insurance involves the assumption of the risk of financial loss by a party other than the patient. Describe how insurance companies can afford to assume such risk.
Q5) One major difference between a PPO and an HMO is:
A) Under PPOs, patients can choose any health care provider without penalty
B) HMOs require co-pays
C) HMOs do not typically reimburse for out-of-network providers
D) PPOs require co-pays
Q6) Insurance policies that supplement Medicare coverage are called _________.
Q7) Explain the difference in healthcare coverage between an HMO and PPO for the patient.
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Chapter 8: Health Information Management Issues in Other Care Settings
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Q1) Literally, the study of x-rays or radiographs is called ________.
Q2) The accrediting agency unique to ambulatory care is the _________.
Q3) The extracorporeal elimination of waste products from blood is most likely to be performed at a:
A) Dialysis center
B) Laboratory
C) Radiology center
D) Rehabilitation center
Q4) All of the following services may be provided in a physical medicine and rehabilitation facility EXCEPT:
A) Industrial rehabilitation
B) Recreational therapy
C) Substance abuse rehabilitation
D) Vocational counseling
Q5) Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986. How has this law changed the way hospitals handle indigent patients?
Q6) The mandated minimum data set for ambulatory care patients is the ________.
Q7) The accrediting agency for rehabilitation is the ___________.
Q8) All facilities seeking Medicare reimbursement are regulated by __________. Page 11
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Chapter 9: Managing Health Records
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Q1) What is the best reason why facilities prefer to manage their MPI electronically?
A) To prevent duplicates
B) To keep track of the length of stay
C) To easily inform attending physicians which patients have been admitted
D) For insurance reimbursement purposes
Q2) A numerical patient record identification system, in which the patient is given a new number for each visit, but with each new admission the previous record is retrieved and filed in the folder with the most recent visit, is called __________ numbering.
Q3) The identification of the physical file folder that contains the health care record can either be alphabetical or numerical. List and describe each of the numerical identification systems.
Q4) The __________contains patient and encounter information often used to correlate the patient to the file identification.
Q5) It is important for the HIM department to locate records in a timely manner. Identify and describe the system used to locate medical records within a facility.
Q6) The length of time that a record must be retained is called the ____________.
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Page 13
Chapter 10: Statistics
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Sample Questions
Q1) Compute the length of stay for the following patient: Admitted 5/25/2012 Discharged 5/25/2012
A) 0 days
B) 1 day
C) Cannot be determined
D) None of the above
Q2) Compute the nosocomial infection rate (A&C).
Q3) The length of stay for Patient H is _______________.
Q4) Diagnosis, physician, or procedure ________________ are used to organize and retrieve specific data from the HIM database.
Q5) What rate is used to indicate the percentage of the hospital's beds occupied by inpatients for a given time period?
A) Percent occupancy
B) Total length of stay
C) Inpatient bed occupancy rate
D) Both a and c
Q6) The length of stay for Patient B is _______________.
Q7) The length of stay for Patient D is _______________.
Page 14
Q8) A frequency distribution organizes data into groups called ________________.
Q9) Explain the difference between aggregate and patient-specific data.
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Page 15
Chapter 11: Quality and Uses of Health Information
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Q1) To improve quality according to a standard, a health care facility may use ___________, the comparison of itself to a similar or superior performer.
Q2) The assignment of deemed status grants Medicare COP certification when a facility is accredited by which organization?
A) NCQA
B) TJC
C) NIAHO
D) Both b and c
Q3) Under what initiative do health care facilities transmit performance measures to TJC:
A) NPSG
B) HCQIP
C) SOW
D) ORYX
Q4) A quality improvement effort regarding completion of the patient advance directive would require an _______________ team.
Q5) Health information may be analyzed to support a _________ campaign to promote the facility within its community.
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Chapter 12: Confidentiality and Compliance
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Q1) Explain informed consent. List three ways that a patient can consent to medical treatment.
Q2) The period in which lawyers are preparing their case and obtaining documents and testimonies is called ______________.
Q3) Under what circumstances will a release of information be denied? Name at least four.
Q4) The giving of information to another, whether oral, photocopies, faxes, e-mails, etc., is called ________________.
Q5) List two types of "sensitive" records. Describe what type(s) of additional controls should be in place to manage these records.
Q6) How are security breaches in electronic health records tracked?
A) Audit trails
B) Indexing
C) All health care personnel should have access to all patient medical records.
D) None of the above
Q7) What information is provided when there is a breach of confidential health information? Who is responsible to conduct this investigation?
Q8) The _____________ brings a lawsuit against the ___________.
Page 17
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Chapter 13: Him Department Management
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Q1) Why is reference material an important resource to an HIM department? What reference tools would you prefer to keep in your HIM department? Name at least three reference tools and why you would want to keep them.
Q2) Policy and procedures should be updated:
A) Annually and as needed due to change
B) Only as needed due to change
C) By the CEO
D) By the nursing administrator
Q3) The HIM department is allowed $300 per month for supplies. At the end of the third quarter, the department has spent $3000 on supplies. This means that the HIM department is:
A) Under budget YTD by $300
B) Over budget YTD by $300
C) Exactly as it should be on supplies
D) Over budget by $250
Q4) ________________ are set guidelines explaining how much work an employee must complete.
Q5) A formal list of the employee's responsibilities associated with his or her job is called a ________________.
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Chapter 14: Training and Development
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Q1) What qualities do successful teams have? Name at least three qualities.
Q2) The period of time, also known as a grace period, given to a new employee to learn the job and reach the performance standards associated with that job is known as the
Q3) The HIM department communicates routinely with physicians regarding everything EXCEPT:
A) Record completion
B) Documentation of health information
C) Release of information
D) The physician's weekend plans
Q4) All of the following are leadership qualities EXCEPT:
A) Delegate responsibilities
B) Encourage continuous improvement
C) Maintain a "closed door" policy
D) Lead by example
Q5) Why is communication essential to an HIM department? With which stakeholders do HIM professionals need to communication regularly?
Q6) An ______ is used to organize the topics to be discussed during a meeting.
Q7) How is development different from training?
Q8) Why is it important for HIM employees to be aware of infection control?
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