Introduction to Health Information Management
Exam Answer Key
Course Introduction
Introduction to Health Information Management explores the fundamental principles and practices involved in managing health information within healthcare organizations. This course covers the collection, storage, analysis, and protection of patient health data, emphasizing the importance of confidentiality, accuracy, and regulatory compliance. Students will gain an understanding of health information systems, electronic health records (EHRs), coding and classification systems, and the legal and ethical considerations of health information management. The course also examines the role of health information professionals in supporting quality care, effective decision-making, and smooth healthcare operations.
Recommended Textbook Health Information Technology 3rd Edition by
Nadinia A. Davis
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14 Chapters
874 Verified Questions
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Page 2
Chapter 1: Health Care Delivery Systems
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Sample Questions
Q1) When one physician asks another physician for an opinion regarding the care of a patient, the first physician is asking for a ____________.
Answer: consultation
Q2) A Primary Care Physician will be most likely to perform which of the following?
A) Remove breast tumor
B) Take a chest x-ray
C) Analyze routine blood test results
D) A colonoscopy
Answer: C
Q3) Is there a difference between an MD and a DO? What kind of professionals are these?
Answer: Professionals with either an MD or a DO are considered medical doctors. Both professionals are licensed and accredited to prescribe medical treatment to patients and order patients to undergo therapeutic care. The difference between these two suffixes is a reflection of the medical school education they complete.
Q4) Medicare waives compliance audits for appropriately accredited facilities by granting them _________.
Answer: deemed status
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3
Chapter 2: Collecting Health Care Data
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Sample Questions
Q1) How does the quantity of health data affect our understanding of what it contains?
Answer: Voluminous data are virtually impossible to understand unless they are put in some context, summarized, or otherwise organized. Before data become meaningful, that is, before they become information, they must be sorted, categorized, labeled, and analyzed.
Q2) An electronic health care system that allows physicians to enter their orders through a computer is called:
A) Barcode Medication Administration
B) Electronic Health Record
C) ADT
D) CPOE
Answer: D
Q3) Which of the following is an example of demographic data?
A) Address
B) Marital status
C) Race
D) Employer
Answer: A
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Chapter 3: Electronic Health Records
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Q1) A series of steps to produce a final result or outcome, which describes how the electronic record moves from one electronic component or work area (queue) to another, is called _______.
Answer: workflow
Q2) A method used to identify records in an electronic system is called __________.
Answer: indexing
Q3) Which of the following technologies is approved by HIMSS for EHR use?
A) CPOE
B) Bedside terminals
C) Handheld computers
D) All of the above
Answer: D
Q4) The ONC's strategic plan has how many goals?
A) One
B) Two
C) Four
D) Eight
Answer: C
Q5) The result of a patient's treatment is called the ___________.
Answer: outcome
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Chapter 4: Acute Care Records
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Q1) The attending physician provides a(n) _____________ to explain the reason for admission.
Q2) A predetermined set of instructions for a specific set of blood tests, x-rays, or other procedures is called:
A) Plan of care
B) Protocol
C) Utilization review
D) Verbal orders
Q3) Obstetrical records differ from other types of acute care records because:
A) Prenatal care data is collected earlier and transferred to the hospital
B) Obstetricians are not required by the TJC to collect a patient history and physical
C) The newborn is not considered an admission
D) The mother is not considered an admission
Q4) List the UHDDS elements of a patient abstract. Explain how this information is captured.
Q5) In urgent situations, a physician's office may call a facility in advance to order an admission. This is called a ____________.
Q6) 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 health information management department can verify which patient records are available for processing by referring to the:
A) Admission register
B) Audit trail
C) Discharge register
D) Exception list
Q2) Parts of paper records that arrive in the HIM department separately from the main record are often called ______________.
Q3) In a paper environment, records must physically move from the patient care area to the HIM department for processing and storage. Give two examples of how that movement can occur.
Q4) Developing a universal chart order will theoretically eliminate which one of the following HIM functions?
A) Chart analysis
B) Deficiency detection
C) Chart assembly
D) Retrospective review
Q5) A computer can create a log of processing and access activities called an
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Chapter 6: Code Sets
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Sample Questions
Q1) Current code sets under HIPAA include all of the following EXCEPT:
A) ICD-9-CM, Volumes I, II, and III
B) National Drug Codes
C) HCPCS and CPT-4
D) ICD-10-PCS
Q2) An example of a CPT-4 code is:
A) C1715
B) 0DJD8ZZ
C) I20
D) 43251
Q3) Representatives of which of the following groups of entities or organizations comprise the "Cooperating Parties?"
A) AHA, AHIMA, CMS, NCHS
B) AHA, AHIMA, AMA, NCHS
C) AHA, AMA, CMS, NCHS
D) AHIMA, AMA, CMS, NCHS
Q4) _____________ must be used under HIPAA for the electronic exchange of data for certain transactions, namely encounter and payment data.
Q5) Describe the difference between nomenclature and classification.
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Chapter 7: Reimbursement
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Sample Questions
Q1) A hospital's case mix index is derived by:
A) Organizing each DRG by rank, with the patients in the most frequently occurring DRG listed as #1, and so forth
B) Adding all DRG relative weights together and then dividing by the total number of cases discharged in a given time period
C) Neither a nor b; case mix index is assigned by the federal government using special software
D) Both a and b
Q2) Insurance policies that supplement Medicare coverage are called _________.
Q3) The type of insurance that assumes the payment for all or part of certain, specified services, but requires out-of-pocket deductibles and frequently caps total covered payments is called _____________.
Q4) A managed care organization that contracts with a network of health care providers to render services to its members is a ___________.
Q5) The systematic collection of specific charges for services rendered to a patient is called ___________.
Q6) How would someone use an unbilled list (DNFB)?
Q7) The federal law that established Medicare PPS is __________.
Page 9
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Chapter 8: Health Information Management Issues in Other Care Settings
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Q1) The mandated minimum data set for ambulatory care patients is the ________.
Q2) The accrediting agency for rehabilitation is the ___________.
Q3) Ambulatory care services are for which type of patients?
A) Primary care physician office visit
B) Overnight observation at hospital
C) Hospice care visit
D) Behavioral health care visit
Q4) Describe the characteristics of a physician group practice, including the administrative advantages.
Q5) The unit of measure for the volume of ambulatory care services provided is either an ________ or a ____________.
Q6) Ambulatory care accreditation is offered by TJC and:
A) AAAHC
B) AARP
C) CHAP
D) NCIPC
Q7) Describe the characteristics and limiting factors of ambulatory surgery services.
Q8) Describe the unique data collection issues in rehabilitation.
Q9) The accrediting agencies for home health care are __________ and Page 10
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Page 11
Chapter 9: Managing Health Records
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Sample Questions
Q1) _________and ___________are legacy storage methods for paper records using plastic film.
Q2) ABC Hospital is planning to expand its medical records file room next year. The hospital had 2,000 patient this year and plans to have 20% more patients next year. The average file width is 0.5 inch each. If the new cabinets have five shelves and each shelf holds 36 inches of files, how many file cabinets will ABC Hospital need next year?
A) 5
B) 7
C) 6
D) 12
Q3) ______________ is a method for planning and preparing to handle catastrophes and other emergencies that can adversely affect the normal performance of the health care environment.
Q4) 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.
Q5) In a ______________ system, the patient record is filed under the same number for all visits.
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Chapter 10: Statistics
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Sample Questions
Q1) Primary data is originally reported or recorded by:
A) the Centers for Disease Control and Prevention
B) researchers at teaching hospitals
C) HIM employees reviewing the record
D) clinicians treating the patient
Q2) Frequency distributions that are not symmetrical are ______________ .
Q3) as the way in which a variance of values behaves over time is called a _________________.
Q4) The length of stay for Patient A is _______________.
Q5) Zak was admitted to the hospital on August 20 and discharged on October 6. The length of stay is _______ days.
A) 47
B) 48
C) 66
D) 67
Q6) Another name for a data illustration is a ________________.
Q7) Explain the difference between a population and a sample.
Q8) An organization of data elements in rows and columns is called a
Q9) The length of stay for Patient G is _______________. Page 13
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Page 14
Chapter 11: Quality and Uses of Health Information
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Sample Questions
Q1) Some HIM departments sometimes choose to perform concurrent review instead of retrospective review, most likely because:
A) Concurrent review is more time efficient.
B) Retrospective review is more time efficient.
C) Retrospective review cannot affect care for patients who have already been discharged.
D) Concurrent review cannot affect care for patients who have already been discharged.
Q2) How has HITECH legislation affected the use of health data to improve patient care?
Q3) Compare and contrast the difference between prevalence and incident. Why is it important to know both?
Q4) Health information may be used in ___________to support the plaintiff's claim.
Q5) Physicians may perform _______ to determine the cause or best treatment for a particular disease.
Q6) The review of the record performed postdischarge is known as _________.
Q7) What is the difference between mortality and morbidity?
Q8) List three appropriate requests for health information from an entity outside of the health care facility.
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Chapter 12: Confidentiality and Compliance
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Sample Questions
Q1) List and describe the steps in processing a request for a copy of a health record.
Q2) Which of the following scenarios represents a HIPAA violation?
A) Nurses discussing Mrs. Logan's patient care inside Mrs. Carter's room
B) An HIM employee discusses the neighbor's medical history with their mother
C) A hospital employee reviewing the electronic medical record of a celebrity currently admitted to the facility
D) All of the above
Q3) An insurance company may obtain patient records by all of the following EXCEPT:
A) Prospective consent under the conditions of admission
B) By subpoena for disclosure of chemical dependency information
C) Prospective consent obtained when the patient became insured
D) Retrospective consent obtained after the patient is discharged
Q4) The responsibility for harm or damage caused by actions or inactions is known as:
A) liability
B) tort
C) negligence
D) malpractice
Q5) The process of engaging in the legal proceedings of a lawsuit is ___________.
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Chapter 13: Him Department Management
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Sample Questions
Q1) 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
Q2) A formal list of the employee's responsibilities associated with his or her job is called a ________________.
Q3) Diamonte Hospital's fiscal year runs from October 1 through September 30. Which of the following months are in the third quarter?
A) January, February, March
B) April, May, June
C) July, August, September
D) October, November, December
Q4) Once standards have been established, the work performance of the employees must be monitored. What happens if the standards are not met consistently?
Q5) 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.
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Chapter 14: Training and Development
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Sample Questions
Q1) The first item on the monthly HIM department meeting agenda is:
A) Call to order
B) Review of old business
C) New business
D) Adjournment
Q2) All HIM professionals should recognize that their __________ are accompanied by a commitment to lifelong learning.
Q3) The term used to describe the training to familiarize a new employee with the job is
Q4) What are some topics that will be discussed during an organization-wide orientation? Name at least four.
Q5) Although trainers do not need to know each employee individually, they do recognize that employees have different learning styles. In what ways can training sessions be formatted? Provide an example of these three training formats. Do all three training formats need to be used for the same session? Why or why not?
Q6) Building safety and security is often included in an organization-wide orientation. Name and discuss two of the safety and security topics commonly included in a healthcare environment orientation.
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