1. What organization sought to improve surgical results by requiring that hospitals keep records
in addition to other minimum standards?
A. American Hospital Association
B. American Medical Association
C. American College of Surgeons
D. American Health Information Management Association
E. Association of Record Librarians
2. In the early days of HIM, hospitals began hiring medical record clerks to ensure that medical
records were complete and stored appropriately due to which of the following programs?
A. Facility Standardization
B. Health Record Standardization
C. Surgical Standardization
D. Data Standardization
E. Hospital Standardization
3. The American Health Information Management Association was previously known as the:
A. American Association of Record Librarians.
B. American Medical Record Association.
C. Association of Record Librarians of North America.
D. None of the above
E. All of the above
4. The process of standardizing forms by using certain forms for specific purposes is called:
A. forms control.
B. documentation control.
C. standardized record control.
D. hospital paperwork control.
E. standardization of documentation control.
5. Which of the following is the responsibility of the hospital health information management
department?
A. Assuring the accuracy of the medical record
B. Coding of the medical record
C. Abstracting information from the medical record
D. Compiling forms for the medical record
E. All of the above
6. The Health Insurance Portability and Accountability Act (HIPAA):
A. establishes specific standards for data codes and data sets.
B. requires security policies for patient information stored electronically.
C. mandates protection for the privacy of patient records.
D. None of the above
E. All of the above
7. In 1991, the American Medical Record Association became the:
A. American Health Information Management Association.
B. Health Information and Management Systems Society.
C. American Medical Informatics Association.
D. National Association for Healthcare Quality.
E. Association for Healthcare Documentation Integrity.
8. Most facilities have an electronic medical record.
A. True
B. False
9. Which of the following positions is responsible for both the health information management
department and the information technology department?
A. Hospital administrator
B. Chief information officer
C. Health information manager
D. Risk manager
E. Chief of staff
10. Information technology technicians maintain and enter health information into computers.
A. True
B. False
11. Hiring a company outside of the healthcare facility to provide a specific service is often
referred to as:
A. outsourcing.
B. enhancing.
C. collaborating.
D. partnering.
E. affiliating.
12. Healthy Heart Hospital needs to hire a professional to validate data and perform clinical
research reports. Which of the following should they hire?
A. Health Information Manager
B. Registered Health Information Administrator
C. Registered Health Information Technician
D. Clinical Data Specialist
E. Clinical Coding Specialist
13. Specialists who review patient charts and assign diagnosis codes in addition to codes for
the procedures and services received are called:
A. health information managers.
B. registered health information technicians.
C. clinical data specialists.
D. clinical coding specialists.
E. health information administrators.
14. Changes, updates, and/or revisions are made to codes:
A. annually.
B. every other year.
C. every 5 years.
D. every 10 years.
E. as needed.
15. The responsibility of the DRG Coordinator is to:
A. optimize reimbursement through correct billing and documentation.
B. review patient records for incomplete data.
C. perform clinical research reports.
D. protect medical record data.
E. enforce confidentiality.
16. Reports such as discharge summaries, history and physicals, and operative reports are
created by listening to a dictated report by which of the following positions?
A. Optical imaging coordinator
B. Clinical analyst
C. Medical transcriptionist
D. Clinical vocabulary manager
E. HIM compliance specialist
17. This position ensures that healthcare data used for coding and reimbursement, records, and
documentation is accurate and consistent.
A. Data resource administrator
B. Data quality manager
C. Clinical applications coordinator
D. APC coordinator
E. Clinical analyst
18. HIPAA requires that healthcare facilities have a security officer position.
A. True
B. False
19. The American Health Information Management Association offers which of the following
credentials by a certification exam?
A. Certified Coding Specialist
B. Registered Health Information Technician
C. Registered Health Information Administrator
D. None of the above
E. All of the above
20. An organization composed of healthcare experts and information professionals who create
standards for exchange, management, and integration of electronic health information is called:
A. Healthcare Level Seven.
B. Hospital Level Seven.
C. Health Provides Seven.
D. Health Level Services.
E. Health Level Seven.
21. A not-for-profit organization that ensures cancer registry professionals have the required
knowledge by providing education and credentialing.
A. National Cancer Registrars Association
B. Association for Healthcare Documentation Integrity
C. American Medical Informatics Association
D. Healthcare Information and Management Systems Society
E. American National Standards Institute
22. The Association for Healthcare Documentation Integrity was formally known as the:
A. American Association for Medical Transcription.
B. American Medical Record Association.
C. American College of Surgeons.
D. American Medical Informatics Association.
E. Association of Healthcare Documentation.
23. Most professional organizations offer memberships to students at a reduced pricE.
A. True
B. False
24. The top supervisory position in an ambulatory care facility is usually a:
A. medical assistant.
b patient information coordinator.
C. medical office manager.
D. data quality manager.
E. health information director.
25. A(n) ________analyzes the workflow of the electronic medical record and works to make it
as efficient as possible
A. clinical vocabulary manager
B. clinical analyst
C. clinical project manager
D. clinical applications coordinator
E. information services director
26. Standardized codes or terms are also often referred to as:
A. clinical terminologies.
B. nomenclatures.
C. vocabularies.
D. All of the above
E. None of the above
27. An integration architect is responsible for:
A. developing and managing the HL7 interfaces.
B. ensuring data is available throughout the organization.
C. testing software designs.
D. supervising network security.
E. maintaining complete electronic medical records.
28. Which of the following is NOT a responsibility of the data quality manager?
A. Audit the quality of data
B. Ensure documentation is consistent
C. Optimize reimbursement
D. Review the data entry process
E. Ensure documentation is accurate
29. The responsibility of the IT (information technology) manager includes:
A. strategic planning.
B. development of new information systems.
C. supervising the computer network.
D. database administration.
E. All of the above
30. Clinical analysts and clinical applications coordinators have the same responsibilities.
A. True
B. False
31. Which of the following positions is responsible for ensuring that an organization’s data is
secure?
A. Clinical vocabulary manager
B. Solution consultant
C. Health systems specialist
D. Data resource administrator
E. Clinical data specialist
32. An enterprise application specialist is responsible for:
A. verifying coded data.
B. training employees on privacy.
C. managing the quality improvement program.
D. monitoring clinical practices.
E. ensuring that data stored in different systems is available throughout the organization.
33. A coding specialist is also sometimes called a(n):
A. claims examiner.
B. insurance specialist.
C. payment specialist.
D. billing department specialist.
E. financial specialist.
34. Students interested in a career in biomedical and health informatics would benefit from a
student membership in which of the following organizations?
A. American National Standards Institute (ANSI)
B. American Medical Informatics Association (AMIA)
C. Association for Healthcare Documentation Integrity (AHDI)
D. American Medical Association (AMA)
E. American Academy of Professional Coders (AAPC)
35. Medical assistants perform:
A. both administrative and clinical tasks.
B. only administrative tasks.
C. only clinical tasks.
D. neither administrative nor clinical tasks.
E. None of the above
36. A ________ management specialist helps increase patient safety by analyzing risk,
educating patients, and educating employees.
A. coding
B. safety
C. risk
D. data
E. research
37. Healthy Heart Hospital has a position open in which the primary responsibility is to develop
policies and procedures to ensure compliance with contractual obligations, regulations, and
ethics. They are looking to hire a:
A. compliance officer.
B. project manager.
C. risk management specialist.
D. privacy officer.
E. solution analyst.
38. All of the following are responsibilities of the health information manager EXCEPT:
A. enforcing confidentiality.
B. managing health information management systems.
C. implementing policies and procedures.
D. assigning standard codes for patient diagnoses.
E. coordinating preparation for audits.
39. Medicare uses which of the following to determine reimbursement for outpatient claims?
A. Procedure modifiers
B. International Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM)
C. Healthcare Common Procedure Coding System (HCPCS)
D. Diagnosis Related Groups (DRG)
E. Ambulatory Payment Classification (APC)
40. Health information technicians are responsible for keeping computer systems operating.
A. True
B. False
41. The ________ called for the creation of an electronic patient record in 1991.
A. American Health Information Management Association
B. Institute of Medicine
C. American Medical Association
D. American Hospital Association
E. Healthcare Information and Management Systems Society
42. This professional organization strives to improve the performance of medical group practice
professionals.
A. American Health Information Management Association
B. Healthcare Information and Management Systems Society
C. National Association for Healthcare Quality
D. Medical Group Management Association
E. American Medical Informatics Association
43. The American Health Information Management Association has a code of ethics that is
followed by:
A. all AHIMA members.
B. credentialed nonmembers.
C. most health information management departments.
D. All of the above
E. None of the above
44. The acronym EDI stands for:
A. electronic data interchange.
B. electronic data information.
C. educating data instructors.
D. electronic data instructors.
E. electronic digital interchange.
45. A good understanding of workflow can be beneficial for all professionals working with health
information and information technology.
A. True
B. False
46. The position of privacy officer is required by:
A. AHIMA.
B. AMA.
C. AHA.
D. HIPAA.
E. AMIA.
47. What professional organization oversees the use of thousands of standards and guidelines?
A. American Health Information Management Association
B. American College of Medical Practice Executives
C. Medical Group Management Association
D. American Medical Informatics Association
E. American National Standards Institute
48. Both the health information management and information technology departments of
healthcare facilities should maintain separate roles and responsibilities.
A. True
B. False
49. ________ allied health positions do NOT involve direct patient care but do manage and
protect patient medical information.
A. Nonclinical
B. Clinical
C. Supportive
D. Clerical
E. None of the above
50. Taking a course in ________ would be beneficial for anyone considering a career in health
information or information technology
A. anthropology
B. medical terminology
C. microbiology
D. psychology
E. a foreign language
1. The abbreviation for Centers for Medicare and Medicaid Services is:
A. CMS.
B. CMMS.
C. CMSS.
D. CCMS.
E. CCMS.
2. Healthcare coverage is provided by Medicare for those:
A. 55 and older.
B. with kidney failure.
C. with disabilities.
D. All of the above
E. None of the above
3. Medicare and Medicaid are both governed by the American Medical Association.
A. True
B. False
4. Companies that have a contract to handle claims for Medicare and Medicaid for a state or
region are called:
A. insurance companies.
B. fiscal intermediaries.
C. consultants.
D. government offices.
E. healthcare contractors.
5. People who are poor, blind, or pregnant may be eligible for help from Medicaid.
A. True
B. False
6. Medicare and Medicaid began in:
A. 1950.
B. 1955.
C. 1960.
D. 1965.
E. 1970.
7. Which of the following is a system developed to pay a fixed amount for inpatient stays based
on the type of case rather than the length of the stay?
A. Discharge payment system
B. Provider payment system
C. Prospective discharge system
D. Patient payment system
E. Prospective payment system
8. Which of the following refers to rules and standards of care developed by Medicare in which
healthcare organizations must comply?
A. Conditions of participation
B. Contracts for participation
C. Accreditation for participation
D. Standards of participation
E. All of the above
9. When a facility meets the requirements of the Joint Commission, Medicare may deem that it
has also met the COP requirements, thereby granting ________ status.
A. incorporated
B. deemed
C. recognized
D. accreditation
E. conditional
10. Which of the following organizations has the power to enforce HIPAA security standards?
A. CMS
B. AHA
C. AMA
D. AHIMA
E. None of the above
11. All states require healthcare facilities to be:
A. registered.
B. accredited.
C. licensed.
D. bonded.
E. regulated.
12. State laws regulate:
A. nursing staff requirements.
B. facility operation.
C. patient records.
D. medical staff requirements.
E. All of the above
13. Politics can influence decisions regarding healthcare facility licensing.
A. True
B. False
14. Licenses are required for:
A. providers who prescribe drugs.
B. operation of a hospital pharmacy.
C. pharmacists who dispense drugs.
D. caregivers who administer drugs.
E. All of the above
15. Healthcare facilities are required to report certain incidents such as:
A. routine surgical procedures.
B. gunshot wounds.
C. child abuse.
D. Both A and B
E. Both B and C
16. JCAHO stands for:
A. Joint Commission on Accreditation of Healthcare Organizations.
B. Joint Committee on Accrediting of Health Organizations.
C. Joint Committee on Accredited Homes.
D. Joint Commission on Accredited Health Professionals.
E. None of the above
17. Benefits of accreditation by the Joint Commission include:
A. enhanced staff development and recruitment.
B. improved risk management.
C. competitive edge in the marketplace.
D. strengthening of community confidence in the healthcare organization.
E. All of the above
18. The name given to the initiative that integrates performance and outcome measures into the
accreditation process is:
A. JCAHO.
B. ORYX.
C. HIPAA.
D. CMS.
E. AHA.
19. The ________ accredits medical laboratories.
A. College of American Pathologists
B. Commission on Accreditation of Rehabilitation Facilities
C. American Hospital Association
D. American Medical Association
E. All of the above
20. A laboratory with CAP accreditation is deemed to have complied with:
A. COP standards.
B. AHA standards.
C. AMA standards.
D. state law.
E. All of the above
21. Accreditation for organizations providing behavioral health, occupational, and physical
therapy services is granted by the:
A. American Medical Association.
B. American Hospital Association.
C. College of American Pathologists.
D. Commission on Accreditation of Rehabilitation Facilities.
E. None of the above
22. HIPAA was passed in 1996 by:
A. Congress.
B. state law.
C. American Hospital Association.
D. American Medical Association.
E. American Health Information Management Association.
23. Health plans, clearinghouses, and healthcare provider entities are covered by which part of
HIPAA law?
A. Security Rule
B. Privacy Rule
C. Administrative Simplification Subsection
D. All of the above
E. None of the above
24. Which of the following is a component of the Administrative Simplification Subsection?
A. Privacy
B. Uniform identifiers
C. Security
D. Transactions and code sets
E. All of the above
25. Each of the following are specific transaction standards for types of electronic data
interchange EXCEPT:
A. claims status.
B. employment status.
C. enrollment and deenrollment in a health plan.
D. first report of injury.
E. premium payments.
26. HIPAA established the ________ Identifier to identify employer sponsored health insurancE.
A. National Provider
B. Employer
C. National Health Plan
D. All of the above
E. None of the above
27. Which HIPAA identifier has NOT yet been implemented?
A. National Provider Identifier
B. Employer Identifier
C. National Health Plan Identifier
D. All of the above
E. None of the above
28. Healthcare providers, insurance companies, and clearinghouses are referred to by HIPAA
documents as:
A. covered entities.
B. providers.
C. contractors.
D. affiliates.
E. partners.
29. It is important for everyone working with patient information to have a clear understanding of
confidentiality.
A. True
B. False
30. PHI refers to:
A. personal health information.
B. professional health information.
C. patient health information.
D. purposeful health information.
E. protected health information.
31. Which of the following is NOT an example of safeguarding a patient’s privacy?
A. Discussing a patient case in the cafeteria
B. Avoiding use of patient names in public areas
C. Speaking quietly when discussing patient information
D. Using passwords to protect information on computers
E. Locking record rooms
32. The HIPAA Privacy Rule replaces any federal, state, or other laws that might grant
individuals greater privacy.
A. True
B. False
33. All of the following are privacy activities in a medical office that would comply with the law
EXCEPT:
A. providing a copy of the office privacy policy informing patients of their privacy
rights and how their information may be used.
B. training employees to understand privacy procedures.
C. having individually identifiable patient information available to all hospital
employees.
D. adopting clear privacy procedures.
E. asking patients to acknowledge receiving a copy of the office privacy policy.
34. A patient agreement to receive medical treatment after having been provided with benefits
and risks is known as:
A. consent.
B. commitment.
C. authorization.
D. informed consent.
E. acknowledgement.
35. Under the HIPAA Privacy Rule, consent refers specifically to:
A. surgical procedures.
B. use of the patient’s information.
C. medication administration.
D. general medical care.
E. All of the above
36. Under HIPAA Privacy Rule, a healthcare provider may disclose PHI without patient
authorization in all of the following situations EXCEPT:
A. as part of a claim for payment from a health plan.
B. to a nursing home a patient is being transferred to.
C. when consulted to provide healthcare to a patient.
D. to a specialist a patient is being referred to.
E. to any family members.
37. A(n) ________ requires the patient’s permission to disclose PHI.
A. authorization
B. consent
C. requirement
D. disclosure
E. None of the above
38. Which of the following are required on an authorization form?
A. Expiration date
B. What can be disclosed
C. Date signed
D. Who the information may be disclosed to
E. All of the above
39. This Privacy Rule standard limits unnecessary or inappropriate access to and disclosure of
PHI beyond what is necessary.
A. Incidental disclosure
B. Health information
C. Access
D. Minimum necessary
E. PHI
40. According to the Privacy Rule, a person authorized to act on behalf of an individual to make
healthcare related decisions is a(n):
A. personal representative.
B. guardian.
C. legal representative.
D. benefactor.
E. emergency contact.
41. Patients may request to see and obtain copies of their medical records in addition to
requesting corrections. Healthcare facilities must provide access to the medical record within
how many days of a request?
A. 5
b.10
C. 14
D. 30
E. 60
42. A patient has the right to know if his or her information was disclosed by a healthcare facility.
A. True
B. False
43. The HIPAA Security Rule covers:
A. protected health information in paper form.
B. protected health information that is stored electronically.
C. insurance information in paper form.
D. insurance information stored in paper format.
E. All of the above
44. Personal health information that is stored electronically is referred to as:
A. EPHI.
B. PHI.
C. PHIE.
D. ERPHI.
E. None of the above
45. The HIPAA Security Rule is enforced by the:
A. OCR.
B. AMA.
C. AHIMA.
D. HIPAA.
E. CMS.
46. The HIPAA security standards include:
A. physical safeguards.
B. administrative safeguards.
C. technical safeguards.
D. All of the above
E. None of the above
47. All of the following are implementation specifications in the Security Management Process
EXCEPT:
A. Risk Management.
B. Patient Information Review.
C. Risk Analysis.
D. Sanction Policy.
E. Information System Activity Review.
48. The ________ Standard includes authorization and/or supervision, workforce clearance
procedures, and termination procedures.
A. Policies and Procedures
B. Documentation
C. Workforce Security
D. Organizational Requirements
E. Access Control
49. Which of the following standards outlines the procedures for limited access to only those
persons or software programs that have been granted access rights by the Information Access
Management administrative standard?
A. Access Control
B. Transmission Security
C. Policies and Procedures
D. Organizational Requirements
E. Person or Entity Authentication
50. The primary goal of the Security Rule is to protect the integrity of the:
A. healthcare providers.
B. EPHI.
C. healthcare facility.
D. PHI.
E. rules and regulations.
51. The Documentation standard includes which of the following implementation specifications?
A. Updates
B. Availability
C. Time limit
D. All of the above
E. None of the above
1. The parts of a computer that can be seen are referred to as:
A. software.
B. hardware.
C. central processing units.
D. hard drives.
E. None of the above
2. The ________ controls the flow of information passing to and from other parts of the
computer.
A. hardware
B. software
C. network
D. central processing unit
E. hard drive
3. Most computers can read and write information.
A. True
B. False
4. Information can be stored on all of the following EXCEPT:
A. the hard drive.
B. optical disks.
C. computer memory chips.
D. hardware.
E. None of the above
5. Which of the following are computer chips with electronic circuits that retain information when
the power is off?
A. Random access memory chips
B. Read-only memory chips
C. Bytes
D. Bits
E. Both a and b
6. Which of the following is an output device?
A. Computer monitor
B. Keyboard
C. Camera
D. Scanner
E. Mouse
7. Which of the following statements is true of RAM?
A. It provides the CPU with the ability to access information it needs.
B. RAM information is only in memory while the computer is on.
C. RAM stands for random access memory.
D. RAM chips keep information in electronic circuits.
E. All of the above
8. The computer’s main storage device is the:
A. hard drive.
B. central processing unit.
C. network.
D. software.
E. hardware.
9. Which of the following statements is NOT true of optical disks?
A. Storage on optical disks is permanent.
B. Optical disks are not affected by magnetism.
C. Optical disks have a long life span.
D. Each optical disk has an unlimited capacity.
E. An optical disk transfers information more slowly than a hard drive.
10. An input device that scans a copy and sends it to the computer as a digital image is called a:
A. scanner.
B. printer.
C. copier.
D. laser.
E. webcam.
11. Examples of input devices include all of the following EXCEPT:
A. keyboards.
B. printers.
C. scanners.
D. mouses.
E. microphones.
12. The study of the physical effect of human/computer interaction on workers with the goal of
minimizing and/or eliminating problems is called:
A. computer interaction effect.
B. computer logistics.
C. ergonomics.
D. Both A and B
E. None of the above
13. An operating system is composed of thousands of little programs and functions that perform
different operations.
A. True
B. False
14. Which of the following is an example of a HIS application?
A. Scheduling software
B. Electronic health records
C. Coding software
D. Email
E. All of the above
15. The smallest unit of information in a computer is called a(n):
A. byte.
B. bit.
C. element.
D. data.
E. character.
16. The ________ standardized text bytes by assigning a meaning to all combinations of bits.
A. HL7
B. HIPAA
C. American Health Information Management Association
D. American Standard Code for Information Interchange
E. American Hospital Association
17. The data type in which numeric data has decimal fractions is called:
A. numeric integer.
B. long integer.
C. double.
D. triple.
E. None of the above
18. ________ data prevents anyone intercepting transmitted packets from making sense of
them.
A. Decrypting
B. Encrypting
C. Coding
D. Rewriting
E. Randomly accessing
19. The smallest dot on a computer screen is a:
A. pixel.
B. bit.
C. byte.
D. data.
E. character.
20. Information that is input is called:
A. bits.
B. data.
C. bytes.
D. pixels.
E. characters.
21. The smallest unit of text data is:
A. bytes.
B. characters.
C. bytes.
D. data.
E. pixels.
22. A database has many different types of records.
A. True
B. False
23. A data dictionary defines:
A. the order of fields in a record.
B. the field name.
C. the type of data a field contains.
D. the maximum length of data a field can contain.
E. All of the above
24. The smallest unit of an image is a:
A. pixel.
B. character.
C. byte.
D. bit.
E. data.
25. Which of the following statements is NOT true of networks?
A. There are many different types of networks.
B. Networks can connect hundreds of computers.
C. Networks do not require special hardware.
D. Networks allow information to be passed from one computer to another.
E. Networks allow computers to share printers.
26. Which of the following are required by networks?
A. A network card
B. A network router
C. Network cables
D. Hardware and software
E. All of the above
27. Computers that are connected by a network serving just the facility in which they are located
are called:
A. local-area networks.
B. single networks.
C. wide-area networks.
D. Internets.
E. clients.
28. ________ cover large geographical areas.
A. Local-area networks
B. Wireless networks
C. Wide-area networks
D. Home networks
E. None of the above
29. LANs and WANs can only be accessed by users within those networks.
A. True
B. False
30. A worldwide public network that can be accessed anywhere by any computer is a(n):
A. local-area network.
B. Internet.
C. wireless network.
D. wide-area network.
E. All of the above
31. Which of the following statements is NOT true of a virtual private network?
A. Uses the Internet to transport packets of data
B. Encrypts and decrypts packets between sending and receiving systems
C. Does not verify the identity of the person signing on
D. Is not limited to web pages
E. Ensures access only to those permitted to use the system
32. A computer that is used only for the generation of reports is a:
A. report server.
B. report database.
C. report hard drive.
D. reporting software.
E. All of the above
33. All of the following are benefits of a networked printer EXCEPT:
A. saves the cost of attaching a printer to every computer.
B. allows use of faster printers and printers with more options.
C. saves desk space attached printers would occupy.
D. can send documents to a printer in another area of the building.
E. All of the above
34. Computer output to laser disk software captures computer output and converts it into a
document file.
A. True
B. False
35. A broad set of standards establishing the types of information that health systems should
keep is called:
A. data elements.
B. data sets.
C. bytes.
D. bits.
E. standards.
36. A list of data elements collected for a specific purpose is a:
A. data code.
B. data set.
C. byte.
D. bit.
E. data standard.
37. All of the following are examples of data elements EXCEPT:
A. demographics.
B. address.
C. next of kin.
D. admission record.
E. insurance information.
38. Which of the following is a nonprofit organization that developed and maintains the leading
messaging standard used to exchange clinical and administrative data between different
healthcare computer systems?
A. American Health Information Management Association
B. American Hospital Association
C. Health Level Seven
D. American Medical Association
E. American Health Informatics Association
39. Any applications that can send and receive HL7 messages can potentially exchange
information.
A. True
B. False
40. Healthcare systems use ________ in place of text in many database fields.
A. procedure codes
B. diagnosis codes
C. lab test codes
D. All of the above
E. None of the above
41. The Clinical Context Object Workgroup standard was developed to allow facilities to make
using applications from multiple vendors for their electronic health record ________ for their
users.
A. more complex
B. slower
C. easier
D. more difficult
E. None of the above
42. Which of the following statements is NOT true of CCOW?
A. Special servers must be set up to handle CCOW functions.
B. CCOW implementation is difficult.
C. CCOW is usually found only in outpatient settings.
D. Each vendor’s application software must be specifically written to enable
CCOW.
E. CCOW makes things easier for the end user.
43. Which of the following is the primary communication tool in all types of business?
A. Word documents
B. Email
C. Letters
D. Interoffice correspondence
E. Telephone conversations
44. Responsibilities for a hospital email system include which of the following?
A. Assigning user email addresses
b Managing an email server
C. Managing email record storage
D. Protecting the system from viruses
E. All of the above
45. Telecommunication systems are increasingly becoming the responsibility of IT departments.
A. True
B. False
46. To retrieve email from a host server operated by an ISP, most healthcare facilities use:
A. POP3.
B. IMAP.
C. SMTP.
D. All of the above
E. None of the above
47. This protocol holds messages on the host server until they are deleted by the user.
A. POP3
B. IMAP
C. SMTP
D. all of the above
E. none of the above
48. The standard protocol for sending messages:
A. POP3
B. IMAP
C. SMTP
D. All of the above
E. None of the above
49. Software that interprets handwritten characters and changes them into typed letters and
numbers is called:
A. handwriting recognition software.
B. chart documentation software.
C. medical record software.
D. transcription recognition software.
E. None of the above
50. Healthcare facilities need to have electronic devices that can be sanitized without being
damageD.
A. True
B. False
1. The word data refers to:
A. records of facts.
B. computer information.
C. patient information.
D. presentation of information.
E. All of the above
2. Which of the following refers to the presentation of patient information in a useful form and
the association of other relevant details with it?
A. Computer data
B. Health information
C. Patient data
D. Health data
E. Consumer information
3. All of the following statements are true of the patient health record EXCEPT:
A. it is not used for billing and reimbursement.
B. it provides information about the patient’s treatment.
C. it is the primary communication document for those who care for the patient.
D. medical bills will not be paid if the patient record does not contain necessary
documentation.
E. it provides information about the patient’s health history.
4. The patient health record is a legal document.
A. True
B. False
5. Information from health records is often used to track:
A. births.
B. exposure to hazardous materials.
C. child abuse.
D. communicable diseases.
E. All of the above
6. Records gathered directly from the patient and his or her providers that document the
patient’s history and state of health are:
A. secondary records.
B. research records.
C. data records.
D. primary records.
E. original records.
7. Records that are created by abstracting and summarizing information from primary records
are:
A. primary records.
B. secondary records.
C. compiled records.
D. research records.
E. summary records.
8. Admission and discharge notes would be found in a chart from which of the following
facilities?
A. Ambulatory care facility
B. Home care agency records
C. Acute care hospital records
D. Rehabilitation clinic records
E. Dental office records
9. All of the following are examples of secondary health records EXCEPT:
A. master patient indexes.
B. reports from other providers.
C. health insurance claims.
D. aggregate data.
E. All of the above
10. Social reasons that are encouraging healthcare providers to move toward electronic health
records include which of the following?
A. Patients are moving more often
B. Patients are changing physicians more often
C. Patients often see multiple physicians
D. The ability to share patient information is important for patient care
E. All of the above
11. Practical reasons for healthcare providers to move to an electronic health record include all
of the following statements EXCEPT:
A. paper records are easily accessed and shared.
B. paper charts must be copied or faxed.
C. handwritten charts can be illegible.
D. searching the contents of a paper chart requires manually opening it and
looking through it.
E. paper charts must be transported from one office to another.
12. The paper patient demographic form is called a(n):
A. admission record.
B. face sheet.
C. data form.
D. history form.
E. patient information sheet.
13. Which of the following documents is NOT a consent form?
A. Consent to treatment
B. Medicare patient rights statement
C. Medical history
D. Advance directive
E. Assignment of benefits
14. A patient history for an ambulatory visit includes:
A. review of systems.
B. family history.
C. history of present illness.
D. chief complaint.
E. All of the above
15. Previous illnesses, operations, injuries, diseases, allergies, and immunizations are all part of
the:
A. past medical history.
B. social history.
C. family history.
D. review of systems.
E. history of present illness.
16. The principle reason for a visit is the:
A. history of present illness.
B. review of systems.
C. chief complaint.
D. social history.
E. past medical history.
17. The acronym SOAP stands for:
A. subjective, objective, assessment, plan.
B. subjective, occupational, assessment, plan.
C. subjective, operative, ailments, plan.
D. subjective, objective, ailments, patient.
E. subjective, objective, assessment, patient.
18. An inpatient admission requires a history and physical within ________ days prior to
admission or 24 hours after admission.
A. 5
b.10
C. 14
D. 28
E. 30
19. All orders, including medications, lab tests, and diagnostic tests, must be:
A. dated.
B. signed.
C. verbally ordered.
D. ordered in person.
E. Both A and B
20. Radiology departments store images such as CT scans, PET scans, and MRIs on a Picture
Archiving and Communication System.
A. True
B. False
21. Surgical procedures require which of the following?
A. Anesthesia records
B. Intraoperative records
C. Informed consent for the procedure
D. Postoperative progress note
E. All of the above
22. All of the following are documented by nurses in an inpatient facility EXCEPT:
A. patient’s social history.
B. administration of medications.
C. treatments ordered by the physician.
D. patient response to treatment.
E. insurance information.
23. A specialist that is asked to see a patient or review a case is a(n):
A. admitting physician.
B. consulting physician.
C. primary physician.
D. discharging physician.
E. referring physician.
24. An attending physician’s request for a consult is called a(n):
A. patient request.
B. medical request.
C. referral.
D. consultation.
E. None of the above
25. Inpatient stays longer than 48 hours require a(n):
A. history and physical.
B. consultation.
C. discharge summary.
D. Both A and B
E. Both A and C
26. Which of the following would NOT be found on a discharge summary?
A. Summary of laboratory results
B. A brief history justifying the need for hospitalization
C. Family history
D. Patient condition at time of discharge
E. Principle and other diagnoses
27. An up-to-date list of both acute and chronic conditions affecting the patient’s care is a(n):
A. history and physical.
B. admission list.
C. problem list.
D. review of systems.
E. problem set.
28. A problem list is required by the Joint Commission on ambulatory charts.
A. True
B. False
29. A discharge summary is required for infants born without complications.
A. True
B. False
30. The birth of a baby requires a document recording the birth to be signed and sent to the:
A. admission office.
B. parents.
C. attending physician.
D. state health department.
E. federal government.
31. A(n) ________ is required in all cases of death.
A. social history
B. family history
C. discharge summary
D. review of care
E. autopsy
32. A physician updates a patient’s home health certification/plan of care every ________ days.
A. 10
B. 14
C. 30
D. 60
E. 90
33. Home health agencies use the OASIS standard to document data that is sent electronically
to the state and CMS every ________ days.
A. 10
B. 14
C. 28
D. 60
E. 120
34. Health information professionals use which of the following to ensure quality patient
records?
A. Data sets
B. Data elements
C. HIM policies
D. HIM procedures
E. All of the above
35. Data elements may require several fields.
A. True
B. False
36. A list of data elements collected for a particular purpose is:
A. a data set.
B. data information.
C. data fields.
D. a data list
E. None of the above
37. Which of the following data sets are used in acute care hospitals and required by CMS?
A. Uniform Ambulatory Care Data Set
B. Uniform Clinical Data Set
C. Minimum Data Set
D. Outcome and Assessment Information Set
E. Uniform Hospital Discharge Data Set
38. All of the following documentation guidelines have been developed by AHIMA EXCEPT:
A. the health record should be organized systematically.
B. only authorized individuals should be allowed to enter documentation in the
health record.
C. all entries in the health record should not be permanent.
D. authors of entries should be clearly identified in the health record.
E. only approved abbreviations and symbols should be used in the health record.
39. Errors in a paper health records should be corrected by FIRST:
A. erasing the error.
B. drawing two lines through the error.
C. drawing one line in ink through the error.
D. drawing an “x” over the error.
E. Any of the above are acceptable.
40. Errors must never be obliterated.
A. True
B. False
41. The ________ attempted to make patient records available to providers that were members
of larger healthcare organizations.
A. electronic medical network
B. integrated delivery network
C. national health information network
D. patient information network
E. patient health record network
42. In 2004, the National Coordinator for Health Information Technology position was
established by:
A. Bill Clinton.
B. George Bush, Jr.
C. Dick Cheney.
D. Dr. Richard Carmona.
E. George Bush, Sr.
43. The exchange of health information across medical practices and facilities owned by
different entities for better patient well-being is encouraged by regional health information
organizations.
A. True
B. False
44. Obstacles when forming a RHIO include:
A. technical issues.
B. economic issues.
C. political issues.
D. All of the above
E. None of the above
45. Who owns the patient health record?
A. The facility or practice
B. The patient
C. The federal government
D. The state
E. All of the above
46. The acronym PHR stands for:
A. provider health record.
B. personal health record.
C. patient health record.
D. private heath record.
E. preventative health record.
47. Which of the following is NOT an advantage of the PHR?
A. Patients enter the information themselves.
B. Patients can retrieve their own records.
C. The record can be retrieved using the Internet.
D. It can integrate information from many different providers.
E. It can integrate information about medications.
48. All of the following statements about E-visits are true EXCEPT:
A. the E-visit is kept separate from the patient chart.
B. E-visits can be handled by the “doctor on-call.”
C. E-visits are not appropriate for new patients who have never been seen at the
practice.
D. E-visits are used for non-urgent visits.
E. a clinician can prescribe medications during an E-visit.
49. Communication technology used to deliver medical care to a patient in another location is
called:
A. remote clinical technology.
B. telemedicine.
C. rural healthcare technology.
D. telocare technology.
E. None of the above
50. Which of the following statements is TRUE about teloradiology?
A. It transmits diagnostic images between two locations.
B. Transmitted images are read by a radiologist on the receiving end.
C. It may be used to obtain a second opinion.
D. Radiologists on the receiving end must be licensed by the state in which the images were
sent from.
E. All of the above
1. Electronic health records present information in a format similar to paper health records.
A. True
B. False
2. Which of the following is a method of organizing a patient chart according to the source of the
document?
A. Problem-oriented medical record
B. Integrated record
C. Source-oriented medical record
D. Office-oriented medical record
E. Physician-oriented medical record
3. A document that serves as an index to a problem-oriented medical record is a(n):
A. review of systems.
B. history and physical.
C. problem list.
D. chart note.
E. review sheet.
4. Which of the following is a method of organizing a patient chart by diagnosis or medical
problem?
A. Problem-oriented medical record
B. Integrated record
C. Source-oriented medical record
D. Office-oriented medical record
E. Physician-oriented medical record
5. A(n) ________ intermingles documents from various sources and is arranged sequentially by
date.
A. problem-oriented medical record
B. source-oriented medical record
C. office-oriented medical record
D. date-oriented medical record
E. integrated medical record
6. All of the following are advantages of the integrated chart method EXCEPT:
A. it is easier to add more pages to the chart.
B. the most recent progress notes are on top.
C. the most recent notes are probably the most relevant.
D. it is easy to review the most recent visit.
E. you must know the date of a particular item or look through the entire medical record.
7. The electronic health record can display patient data in which of the following formats?
A. Source-oriented medical record
B. Problem-oriented medical record
C. Integrated record
D. Any way requested
E. All of the above
8. Information stored on the electronic health record can be organized and displayed in a variety
of ways because databases store records in a method called:
A. random access.
B. remote access.
C. relative access.
D. reporting access.
E. retrieval access.
9. Systems that use both paper and electronic records are called:
A. double health records.
B. secondary health records.
C. hybrid health records.
D. level one health records.
E. joint health records.
10. An example of a “loose sheet” or a document that may need to be added to a chart at a later
time is a:
A. letter from another clinic.
B. discharge summary.
C. consultation report.
D. lab report.
E. All of the above
11. Medical record filing methods are:
A. alphabetic.
B. numeric.
C. colored.
D. Both A and B
E. Both B and C
12. The goal of a filing method is:
A. easy detection of misfiled or missing charts.
B. quick filing of charts.
C. easy expansion.
D. quick chart retrieval.
E. All of the above
13. To minimize and detect filing errors, labels are often:
A. highlighted.
B. color-coded.
C. flagged.
D. removed.
E. replaced.
14. All of the following statements are true of an alphabetic filing system EXCEPT:
A. it is a difficult system to learn.
B. misfiles can occur easily.
C. alphabetic systems grow unevenly.
D. alphabetic systems require frequent reorganization.
E. charts can be located knowing only the patient name.
15. A filing method in which charts are filed in ascending numeric order is:
A. alphanumeric filing.
B. terminal digit filing.
C. straight numeric order filing.
D. middle digit filing.
E. alphabetic filing.
16. A filing method that uses the last set of the hyphenated record number as the primary set of
numbers for filing is:
A. terminal digit filing.
B. middle digit filing.
C. straight numeric order filing.
D. alphanumeric filing.
E. All of the above
17. A filing method that uses the middle set of numbers as the primary set for filing is:
A. alphanumeric filing.
B. terminal digit filing.
C. straight numeric order filing.
D. middle digit filing.
E. alphabetic filing.
18. In a color-coded filing system, a misfiled chart will easily stand out because there will be a
break in the visual color pattern sequence.
A. True
B. False
19. A patient medical record number is unique to that patient.
A. True
B. False
20. Which of the following is a numbering system in which a new number is assigned for each
admission or ED visit?
A. Unit numbering
B. Serial-unit numbering
C. Family numbering
D. Serial numbering
E. Admission numbering
21. Which of the following is a numbering system in which a medical record number is assigned
the first time a patient is registered and is used every time a patient returns?
A. Unit numbering
B. Serial-unit numbering
C. Family numbering
D. Serial numbering
E. Admission numbering
22. All of the following statements are true of unit numbering EXCEPT:
A. the Joint Commission recommends that unit numbering be used.
B. there is one single medical record.
C. there is one medical record number assigned.
D. most ambulatory care and inpatient facilities use unit numbering.
E. All of the above statements are true.
23. A paper or plastic placeholder that indicates a chart has been removed is a(n):
A. routing guide.
B. filing guide.
C. requisition slip.
D. chart request.
E. outguide.
24. It is the responsibility of the ________ to ensure each patient is assigned a unique chart
number.
A. HIM department
B. billing department
C. nursing department
D. IT department
E. risk management department
25. X-ray films and other radiology records not stored electronically are often stored in:
A. medical records.
B. jackets.
C. bins.
D. drawers.
E. boxes.
26. A second chart may be started for a patient when:
A. the original chart cannot be located.
B. the patient changed names through marriage or divorce.
C. the patient name is not found in the master patient index.
D. serial or serial-unit numbering is used and the previous record was not brought forward.
E. All of the above
27. According to OSHA, the aisle between filing or shelving units must be at least ________ feet
wide.
A. 1
B. 2
C. 3
D. 4
E. 5
28. Which of the following is NOT a measure that can be taken to maintain the security of
patient records?
A. Chemical or halogen fire extinguishers in the record room
B. Access to files by all employees at all times
C. Locks for filing cabinets and/or doors
D. File rooms on the second floor or higher in areas prone to flooding
E. Sprinklers in file rooms
29. How many pages does AHIMA estimate one inpatient stay contains on average?
A. 10
B. 25
C. 50
D. 75
E. 100
30. The electronic health record will eventually eliminate all paper.
A. True
B. False
31. A computer program in document imaging systems that associates various ID fields and
keywords with scanned images is called:
A. cataloging the data.
B. cataloging the image.
C. cataloging the field.
D. cataloging the information.
E. cataloging the patient.
32. Quality control is most important during:
A. scanning and cataloging.
B. storage.
C. transporting.
D. shredding.
E. retrieval.
33. Cataloging documents as the wrong type is called:
A. improper barcoding.
B. improper abstracting.
C. improper batching.
D. improper coding.
E. None of the above
34. Which of the following duties is NOT included in “prepping” the chart?
A. Staples and paperclips are removed.
B. All documents are verified as belonging to the patient.
C. Barcoded divider sheets are printed and inserted between groups of pages.
D. Information to be scanned is sent to primary physician for signature.
E. Pages are examined and batched in correct order.
35. The first step to ensure the record is complete and accurate is to:
A. analyze the record for deficiencies.
B. make sure all items requiring signatures are signed.
C. abstract the record.
D. code the record.
E. file the record.
36. A report listing items missing from the chart is a(n):
A. missing report list.
B. deficiency list.
C. provider information list.
D. medical record abstract.
E. itemized report list.
37. The length of time that records are kept depends on:
A. state law.
B. contract obligations.
C. age of the patient.
D. policies of the facility.
E. All of the above
38. Selecting the patient files that are least likely to be needed and storing them in another
place or format is called:
A. remoting.
B. archiving.
C. inactivating.
D. All of the above
E. None of the above
39. One form of archiving is:
A. copying the chart.
B. microfilming the chart.
C. reviewing the chart.
D. thinning the chart.
E. None of the above
40. Paper medical records are usually destroyed by:
A. shredding.
B. incinerating.
C. recycling.
D. Both a and b
E. Both a and c
41. Healthcare facilities are required to keep track of any disclosure of patient information.
These disclosure records are kept for at least ________ years.
A. 2
B. 3
C. 4
D. 6
E. 10
42. HIPAA regulations require the ________ authorization to release health information.
A. provider’s
B. patient’s
C. HIM manager’s
D. Both a and b
E. Both a and c
43. When medical records are used for legal purposes, it is important that both sides receive
identical copies.
A. True
B. False
44. Professional standards by which health information professionals conduct themselves are
called:
A. standards.
B. obligations.
C. ethics.
D. contracts.
E. codes.
45. The AHIMA Code of Ethics serves which of the following purposes?
A. It provides ethical principles by which the public can hold HIM professionals
responsible.
B. It helps HIM professionals identify relevant considerations when professional
obligations conflict or ethical uncertainties arise.
C. It provides core values on which the HIM mission was based.
D. It socializes new practitioners to the field to HIM’s mission, values, and ethical
principles.
E. All of the above
46. Alleged violation of the AHIMA Code of Ethics is subject to a(n):
A. peer review process.
B. committee interpretation.
C. automatic revocation of credentials.
D. automatic loss of membership.
E. probationary period.
47. Professional values require an individual to put aside personal values.
A. True
B. False
48. The AHIMA Code of Ethics does all of the following EXCEPT:
A. offer ethical guidelines to which professionals aspire.
B. provide guidelines for ethical and unethical behavior.
C. offer ethical guidelines by which a professional’s actions can be judged.
D. set forth values and ethical principles.
E. specify the values, principles, and guidelines that are the most important.
49. Ethical obligations of the HIM professional do NOT include:
A. protection of patient privacy.
B. disclosure of information.
C. quantity of information.
D. development of health information systems.
E. maintenance of health information systems.
50. Which of the following is NOT an ethical principle based on core values of AHIMA?
A. Participate in unethical practices or procedures
B. Recruit and mentor students
C. Put service and the health and welfare of persons before self-interest
D. Represent the profession accurately to the public
E. Advocate, uphold, and defend the individual’s right to privacy
1. The concept of the electronic medical record was originally introduced in 1991 by the:
A. American Medical Association.
B. American Medical Record Association.
C. Institute of Medicine of the National Academies.
D. Agency for Healthcare Research and Quality.
E. Computer-based Patient Record Institute.
2. Electronic health records were previously called:
A. electronic medical records.
B. electronic charts.
C. longitudinal patient records.
D. computer-based patient records.
E. All of the above
3. All of the following are core functions of the electronic health record set forth by the IOM,
EXCEPT:
A. order management.
B. decision support.
C. health information and data.
D. physician support.
E. administrative processes and reports.
4. Which of the following organizations identified three key criteria for electronic health records
that include capturing data, integrating data, and providing decision support?
A. American Health Information Management Association
B. Institute of Medicine of the National Academies
C. Agency for Healthcare Research and Quality
D. Computer-based Patient Record Institute
E. American Medical Informatics Association
5. The HIPAA Security Rule provides protection for all personally identifiable health information
stored in an electronic format.
A. True
B. False
6. Which of the following statements in NOT true regarding Leapfrog?
A. It was formed by a group of employers.
B. It created a strategy that tied the purchase of group health insurance benefits to quality care
standards.
C. It promoted CPOE as a means of reducing errors.
D. All of the above
E. None of the above
7. The Health Information Technology for Economic and Clinical Health Act was signed into law
by:
A. President Barack Obama.
B. President George W. Bush, Jr.
C. President Bill Clinton.
D. President George W. Bush, Sr.
E. None of the above
8. The HITECH Act:
A. mandates an electronic health record by all facilities.
B. authorizes Medicare incentive payments to doctors and hospitals using a
certified her.
C. ensures both a paper and electronic medical record for every patient.
D. All of the above
E. None of the above
9. The ________ was given $50 million by Congress to support efforts to reduce medical errors.
A. Institute of Medicine of the National Academies
B. Computer-based Patient Record Institute
C. American Health Information Management Association
D. Agency for Healthcare Research and Quality
E. American Medical Association
10. All of the following are functional benefits of the EHR EXCEPT:
A. physician identification.
B. trend analysis.
C. alerts.
D. decision support.
E. health maintenance.
11. Discrete data in an EHR may be subcategorized into:
A. fielded data.
B. coded data.
C. informative data.
D. Both A and B
E. Both B and C
12. When a code is stored in the EHR, the record is considered:
A. complete.
B. incomplete.
C. codified.
D. fielded.
E. None of the above
13. The more parts of a medical record that are coded, the less useful the data becomes.
A. True
B. False
14. Nomenclatures are:
A. types of EHRs.
B. EHR coding systems.
C. abstracts.
D. data fields.
E. short abbreviations.
15. ________ are designed to codify the patient-clinician encounter.
A. Data sets
B. Data fields
C. Data abbreviations
D. Nomenclatures
E. Indexing sets
16. An example of a nomenclature is:
A. RHIO.
B. MEDCIN.
C. AHRQ.
D. CPRI.
E. IOM.
17. This medical nomenclature, a merger of two previous coding systems, was developed by
the College of American Pathologists and the United Kingdom’s National Health Service.
A. MEDCIN
B. SNOMED-CT
C. LOINC
D. All of the above
E. None of the above
18. Findings are also referred to as:
A. clinical observations.
B. data.
C. symptoms.
D. signs.
E. None of the above
19. Which nomenclature, a list of medically meaningful findings, was developed for point-of-care
usage by the clinician?
A. MEDCIN
B. SNOMED-CT
C. LOINC
D. All of the above
E. None of the above
20. LOINC standardizes codes for:
A. medical diagnoses.
B. radiology tests.
C. laboratory tests.
D. clinical findings.
E. All of the above
21. An important component of health maintenance is:
A. immunizations.
B. surgical care.
C. preventative care screening.
D. Both A and B
E. Both A and C
22. Health maintenance systems are also known as:
A. healthcare reminder systems.
B. health prevention systems.
C. healthy patient systems.
D. preventative health systems.
E. preventative care systems.
23. Adult immunizations are different from immunizations given to children.
A. True
B. False
24. Which of the following is an independent panel of experts that reviews and makes
recommendations of clinical preventative services?
A. U.S. Preventive Services Task Force
B. Institute of Medicine of the National Academies
C. Agency for Healthcare Research and Quality
D. College of American Pathologists
E. None of the above
25. The BEST way to ensure that preventative services are delivered appropriately is to:
A. send information on preventative care to patients.
B. educate providers on preventative care.
C. make evidence-based information readily available at the time of the patient
visit.
D. hold staff in-services about promoting preventative care.
E. None of the above
26. Computers can use ________ data to compare a patient’s immunizations against an
immunization schedule to determine which immunizations are needed.
A. coded
B. fielded
C. abstracted
D. missing
E. identified
27. Trend analysis can be used to analyze:
A. medication information.
B. laboratory tests.
C. weight.
D. blood pressure.
E. All of the above
28. An example of a trend analysis tool is a(n):
A. history and physical.
B. flow sheet.
C. problem list.
D. progress note.
E. social history.
29. Which of the following is a message or a reminder that is automatically generated by the
EHR system?
A. Alarm
B. Notice
C. Observation
D. Alert
E. Remark
30. The most common alert systems are implemented with prescription systems.
A. True
B. False
31. Which of the following measures prevent medication errors?
A. Physician review of patient allergies
B. Physician consultation of the PDR for drug interactions
C. Medication warnings given to the patient from the pharmacy
D. Use of the Allscripts EHR system by the healthcare facility
E. All of the above
32. Which of the following is a computer program that compares a prescription to a database of
drugs in addition to patient medications, allergies, and other related information to reduce
prescribing errors?
A. Patient medication review
B. Drug utilization review
C. Patient utilization review
D. Drug and medication review
E. Patient medication and drug utilization review
33. Which of the following is NOT a function performed by a DUR program?
A. The drug being prescribed is checked with the patient’s current
medications.
B. The patient’s allergy records are checked.
C. The patient’s diagnosis history is checked.
D. Ingredients of a drug are checked against the ingredients of a drug already
being taken.
E. All of the above are performed by a DUR program.
34. An alert notifying the physician of a drug NOT covered by the patient’s insurance is called
a(n):
A. formulary alert.
B. insurance alert.
C. prescription alert.
D. pharmacy alert.
E. drug utilization review alert.
35. The ability of EHR systems to store or quickly locate materials relevant to the findings of the
current case is referred to as:
A. location support.
B. data support.
C. decision support.
D. information support.
E. clinician support.
36. Which of the following is NOT an example of decision support?
A. Comparison of medication changes
B. Access to medical references
C. Electronic prescription systems
D. Registration of new patients
E. Protocols
37. Data is entered into the EHR by which of the following methods?
A. It is scanned into the EHR.
B. It is imported from another system.
C. It is automatically generated from other reports.
D. It is entered by the patient.
E. All of the above
38. Documenting patient information in the EHR at the time it is happening is called:
A. traditional documentation.
B. automatic documentation.
C. point-of-care documentation.
D. immediate documentation.
E. time-of-service documentation.
39. An example of point-of-care documentation is:
A. entering vital signs at the patient’s bedside.
B. dictating a report after the patient leaves the office.
C. writing nursing notes at the end of the shift.
D. completing SOAP notes on all patient visits at the end of the day.
E. All of the above
40. Which of the following is an automated patient data-entry component of the EHR in which a
patient can enter his or her own data?
A. Instant Medical History
B. Patient Medical History
C. Patient Data History
D. Instant Patient Data
E. Patient Plus
41. The use of computer interviews ________ the quality of the information presented by the
patient.
A. decreases
B. improves
C. changes
D. verifies
E. None of the above
42. The Instant Medical History program can be used by patients:
A. at a kiosk in the waiting room.
B. on the facility’s website through the Internet.
C. with a pen-tablet device in the exam room.
D. All of the above
E. None of the above
43. Which of the following statements is NOT true of a standard nomenclature?
A. It allows the physician to select terminology.
B. It saves the physician time typing.
C. It displays several sentences describing the patient’s condition once a
finding is selected.
D. It creates a codified medical record.
E. It cannot be used for point-of-care data entry.
44. ________ are subsets of standardized nomenclature.
A. Inventories
B. Lists
C. Files
D. Choices
E. None of the above
45. A ________ is used to display a desired group of findings in a presentation that allows for
quick entry of information.
A. data sheet
B. list
C. document
D. form
E. text box
46. All of the following statements are true of the search function on most EHRs, EXCEPT:
A. it will perform an alternate word search.
B. it is not able to perform automatic word completion.
C. it identifies related findings in other sections of the nomenclature.
D. it produces a list of findings almost instantaneously.
E. it is standardized in most EHRs.
47. Lists of tests, treatments, therapies, and plans of care recommended for certain conditions
are called:
A. protocols.
B. order sets.
C. standards.
D. Both A and B
E. Both A and C
48. The electronic medical record does NOT need to be signed after it is completeD.
A. True
B. False
49. An electronic signature must meet all of the following criteria, EXCEPT:
A. the signer must not be able to deny signing the document.
B. the recipient must be able to confirm that it was signed by the real person.
C. the recipient must be able to confirm the document has not been altered since it was signed.
D. All of the above
E. None of the above
50. Multiple providers can access the patient’s EHR simultaneously.
A. True
B. False
1. Which of the following refers to a philosophy of selecting IT systems based on software
compatibility, usually choosing software from one vendor?
A. Best-of-breed approach
B. Software functionality approach
C. Integrated systems approach
D. Custom interface approach
E. Vendor approach
2. Selecting systems based on a department’s need, not the vendor of the software, is the:
A. best-of-breed approach.
B. software functionality approach.
C. integrated systems approach.
D. custom interface approach.
E. vendor approach.
3. Which of the following is NOT an advantage of the best-of-breed approach to selecting
software?
A. It requires the IT department to work with more vendors.
B. It is the system best suited to the needs of a department.
C. It ensures maximum software functionality.
D. All of the above are disadvantages.
E. None of the above are disadvantages.
4. Hospitals generally have more software applications than outpatient facilities.
A. True
B. False
5. An example of information found in a patient registration system is the:
A. organ donor form.
B. admitting diagnosis.
C. medical record number.
D. insurance information.
E. All of the above
6. A system used to provide patient lookup and to prevent duplicate registrations of the same
patient is a(n):
A. registration index.
B. patient file index.
C. master patient index.
D. original registration index.
E. registration file index.
7. A ________ field is used to codify phonetic sounds of surnames.
A. Soundex
B. data
C. mater patient index
D. name
E. phonetic
8. Which of the following is a system that receives orders and sends results of tests performed
by the lab?
A. HIS
B. LIS
C. ADT
D. CPOE
E. NMDP
9. Which of the following would NOT be considered a laboratory service?
A. Pathology
B. Cytology
C. Radiology
D. Microbiology
E. Chemistry
10. All laboratory work is performed by automated equipment.
A. True
B. False
11. Performing gross, microscopic, and molecular examination of organs and tissues, and
autopsies of whole bodies is called:
A. laboratory pathology.
B. clinical pathology.
C. molecular pathology.
D. anatomic pathology.
E. None of the above
12. The FIRST step in the laboratory workflow is:
A. the specimen is obtained from the patient.
B. the lab report is generated.
C. the results are checked by the clinician.
D. the specimen is sent to the lab.
E. the test is ordered by a clinician.
13. Testing that occurs at the patient’s home or bedside is called:
A. remote testing.
B. out-of-laboratory testing.
C. point-of-care testing.
D. self-testing.
E. home testing.
14. Medical laboratories are accredited by:
A. the American Medical Association.
B. the Medical College of Pathologists.
C. HIPAA.
D. the Joint Commission.
E. the American Hospital Association.
15. The word stat me
16. Which of the following is NOT one of the five rights of laboratory testing?
A. Right time
B. Right test
C. Right physician
D. Right results
E. Right patient
17. Physicians who specialize in interpreting diagnostic images are:
A. pathologists.
B. radiologists.
C. ophthalmologists.
d, physiologists.
E. kinesiologists.
18. A card with the patient’s name and/or ID number that is photographed on the negative when
images are captured on film is a:
A. radiology card.
B. film card.
C. identification card.
D. negative card.
E. flash card.
19. Most radiology departments have ________ for storing diagnostic images.
A. RIS and PACS
B. an LIS
C. an IIS
D. a DIS
E. an RDS
20. A set of related images interpreted by a radiologist is called a:
A. set.
B. group.
C. study.
D. combination.
E. profile.
21. Some x-rays are taken with photographic film.
A. True
B. False
22. What does the acronym DICOM stand for?
A. Doctor Imaging and Communications in Medicine
B. Digital Imaging and Communications in Medicine
C. Diagnostic Imaging and Communications in Medicine
D. Detailed Imaging and Communications in Medicine
E. Determined Imaging and Communications in Medicine
23. ________ uses magnetic fields and pulses of energy to create images of organs and
structures inside the body.
A. Computerized axial tomography
B. Positron emission tomography
C. Nuclear scanning
D. X-ray
E. Magnetic resonance imaging
24. Which of the following is a type of imaging that uses x-rays to capture thousands of images
to construct a view of cross sections of the body?
A. Computerized axial tomography
B. Positron emission tomography
C. Nuclear scanning
D. X-ray
E. Magnetic resonance imaging
25. A radiologist’s computer monitor has higher resolution than most computer screens.
Resolution refers to the:
A. size of the pixels a screen can display.
B. number of pixels a screen can display.
C. speed that images can be displayed.
D. both the size and number of pixels a screen can display.
E. both the number of pixels and the speed that images can be displayed.
26. Dictation is transcribed by a:
A. medical assistant.
B. billing specialist.
C. medical transcriptionist.
D. nurse.
E. physician.
27. All of the following statements are true of the dictation/transcription process EXCEPT:
A. it produces a codified medical record.
B. it replaces illegible and/or handwritten notes.
C. it involves a delay between treatment of the patient and availability of the
information.
D. documents are sent to the physician for signature.
E. transcription of reports is an expense for the facility.
28. Transcription charges are based on the:
A. number of lines transcribed.
B. number of words transcribed.
C. visible black characters transcribed.
D. All of the above
E. None of the above
29. Software that translates the sound of human voice into text is called:
A. speech translation software.
B. speech recognition software.
C. automatic recognition software.
D. clinician dictation software.
E. clinician translation software.
30. Which of the following statements is NOT true of speech recognition
software?
A. It can be used to produce a codified medical record.
B. Speech recognition systems improve as they are used.
C. Speech recognition systems can recognize an average of 50% of the words of
most people.
D. Speech recognition systems reduce the cost of transcription.
E. Some facilities that use speech recognition systems continue to employ
transcriptionists.
31. All acute care hospitals have inpatient pharmacies.
A. True
B. False
32. The five rights of medication administration include all but:
A. right medication.
B. right dose.
C. right physician.
D. right route of administration.
E. right time and frequency.
33. After an order is received by the pharmacy, the pharmacist performs a(n) ________ to
reveal any potential problems.
A. drug utilization review
B. prescription review
C. order review
D. patient review
E. pharmacy review
34. In the emergency department, ________ quickly prioritize patient needs, determining how
long treatment can be delayed without deterioration of the condition of the patient.
A. admitting clerks
B. physicians
C. triage nurses
D. receptionists
E. None of the above
35. The emergency department uses software to track all of the following information EXCEPT:
A. staffing assignments.
B. order status.
C. patient location.
D. past medical history of the patient.
E. patient wait times.
36. If a patient is admitted within ________ hours of an emergency department visit, the billing
for the ED visit is cancelled and changed to inpatient billing.
A. 12
B. 24
C. 36
D. 48
E. 72
37. An unconscious patient who cannot be identified and is treated in the emergency
department is especially challenging because:
A. the patient record cannot be accessed.
B. orders require a medical record number.
C. a record will be created with a temporary ID.
D. once the patient is conscious or identified, the record must be modified.
E. All of the above
38. Devices that touch or are attached to patients are the responsibility of the:
A. pathology department.
B. laboratory department.
C. biomedical department.
D. radiology department.
E. nursing department.
39. A(n) ________ is an example of a biomedical device.
A. surgical instrument
B. cardiac monitor
C. x-ray machine
D. patient bed
E. EKG printout
40. Preoperative software includes management and scheduling of:
A. the operating room.
B. equipment.
C. surgical supplies.
D. personnel.
E. All of the above
41. Surgeon ________ specify equipment and supplies used by surgeons for different types of
surgeries.
A. equipment cards
B. surgical cards
C. perioperative cards
D. preference cards
E. surgical detail cards
42. The operative report includes all of the following EXCEPT:
A. preoperative diagnosis.
B. postoperative diagnosis.
C. surgeon’s name.
D. insurance information.
E. date of surgery.
43. Which of the following is a term that describes the entire surgical event, from scheduling
through recovery?
A. Postoperative
B. Preoperative
C. Perioperative
D. Reoperative
E. Intraoperative
44. Which of the following is a device or substance put into the body to serve a particular
purpose?
A. Prosthesis
B. Implant
C. Device
D. Appliance
E. Apparatus
45. The recovery room report documents:
A. the patient’s postanesthesia recovery.
B. complications of the surgery.
C. pathology findings.
D. final sponge count.
E. estimated blood loss.
46. Which of the following refers to tissues or organs put into the body, usually from donors who
have died?
A. Implants
B. Donors
C. Transplants
D. Grafts
E. None of the above
47. Transplant registries maintain information on:
A. donors.
B. potential recipients.
C. recipients.
D. patient status and condition.
E. All of the above
48. All of the following are phases of a clinical trial EXCEPT:
A. patients are given the drug or a placebo.
B. dosage level is determined and proof the drug works.
C. testing on human subjects to determine safety.
D. determination of the cost of the medication.
E. survey of general interaction once it is in general use.
49. Clinical trials sometimes require entry of the same data into two different systems.
A. True
B. False
50. Clinical trials are authorized by the:
A. Joint Commission.
B. U.S. Food and Drug Administration.
C. American Medical Association.
D. hospital’s CIO.
E. College of American Pathologists.
1. Which of the following refer to records created by abstracting relevant details from the
primary records?
A. Data records
B. Electronic records
C. Billing records
D. Secondary records
E. None of the above
2. A health insurance claim is an example of a(n):
A. primary record.
B. secondary record.
C. hospital record.
D. electronic health record.
E. All of the above
3. Which of the following is the FIRST step in the accounting workflow?
A. A computer program generates a paper or electronic claim to be sent to the
insurance plan.
B. The patient is treated and discharged.
C. A claim is sent to the secondary insurance plan.
D. The provider verifies patient insurance eligibility with the health plan.
E. A bill is sent to the patient for the amount that is the patient’s responsibility.
4. The insurance bill is called a(n):
A. statement.
B. claim.
C. billing record.
D. patient account.
E. patient bill.
5. The first step in preparing a claim is to assign procedure and diagnosis codes.
A. True
B. False
6. Which of the following is a document listing each charge, the amount paid by insurance, the
amount written down by the provider, and the amount due from the patient?
A. Open item statement
B. Balance forward patient statement
C. Reimbursement statement
D. Patient bill
E. Patient account
7. Which of the following is a paper or electronic document that explains the amounts that were
paid to the provider?
A. Remittance
B. Remittance advice
C. Reimbursement statement
D. Billing statement
E. Patient bill
8. Which of the following is a payment sent to the provider after a claim has been adjudicated?
A. Remittance
B. Remittance advice
C. Reimbursement
D. Disbursement
E. Contract allowance
9. A(n) ________ claim occurs when the primary insurance plan automatically sends the claim
on to the secondary insurance plan.
A. secondary benefit
B. explanation of benefit
C. coordination of benefit
D. remittance benefit
E. billing benefit
10. After all of the patient’s insurance plans have responded with an EOB, any remaining
amount owed is the responsibility of the:
A. provider.
B. facility.
C. patient.
D. health care plan.
E. None of the above
11. Charges and payments for one period are listed on a(n):
A. open item statement.
B. balance forward statement.
C. remittance advice.
D. claim.
E. billing statement.
12. The acronym EMC stands for:
A. electronic medical claims.
B. emergency medical claims.
C. electronic medical coordination.
D. electronic media claims.
E. employee media committee.
13. Standardized electronic data interchange formats were mandated by:
A. ANSI.
B. HIPAA.
C. AHA.
D. AHIMA.
E. AMA.
14. All eight of the electronic transactions mandated by HIPAA were developed by the American
National Standards Institute (ANSI) Data Interchange Standards Association (DISA) Accredited
Standards Committee (ASC) X12n.
A. True
B. False
15. Which of the following is NOT one of the eight transactions mandated by HIPAA?
A. Remittance and payment advice
B. Referral certification and authorization
C. Claim status inquiry and response
D. Health plan premium payments
E. Quality care response
16. All of the following transaction standards have been finalized EXCEPT:
A. health claims attachment.
B. enrollment and de-enrollment in a health plan.
C. first report of injury for reporting worker’s compensation incidents.
D. Both A and B
E. Both A and C
17. Two different types of claims are used by both Medicare and other insurance plans, one for
professional billing and one for:
A. institutional billing.
B. service billing.
C. surgical billing.
D. outpatient billing.
E. rehabilitation billing.
18. Which of the following medical professionals would bill for their services by using the
professional claim ANSI837-P or CMS-1500?
A. Chiropractors
B. Therapists
C. Physicians
D. Osteopaths
E. All of the above
19. Putting charges and payments into the patient accounting system is called charging.
A. True
B. False
20. Another name for an encounter form is a:
A. superbill.
B. charge ticket.
C. patient invoice.
D. Both A and B
E. Both A and C
21. All of the following are included on an encounter form EXCEPT:
A. patient name.
B. provider name.
C. date of visit.
D. time of visit.
E. All of the above are found on an encounter form.
22. When using batch posting:
A. superbills are posted in batches alphabetically.
B. superbills are gathered into a batch and posted later.
C. superbills are posted together on the same day as the patients were seen.
D. superbills are posted in diagnosis related batches.
E. All of the above
23. The electronic version of a professional claim form is the:
A. ANSI 837-P.
B. CMS-1500.
C. UB-04.
D. ANSI 837-I.
E. None of the above
24. Which of the following refers to the time period after discharge that hospitals wait to ensure
that all of the charges have been collected and coded?
A. Payment floor
B. Billing floor
C. Bill hold period
D. Statement cycle
E. Bill cycle
25. Claims must be submitted within a certain timeframe or they will not be paiD.
A. True
B. False
26. Institutional claims are submitted electronically using which of the following?
A. ANSI 837-P
B. CMS-1500
C. UB-04
D. ANSI 837-I
E. CMS-1450
27. The UB-04 is also known as the:
A. ANSI 837-P.
B. CMS-1500.
C. UB-04.
D. ANSI 837-I.
E. CMS-1450.
28. The specific function of converting data arriving in a noncompliant format into a HIPAA-
compliant format is performed by a:
A. third party payer.
B. clearinghouse.
C. hospital billing department.
D. billing clerk.
E. All of the above
29. Fees charged for using a clearinghouse are paid by the:
A. health plan.
B. healthcare facility.
C. patient.
D. All of the above
E. None of the above
30. Software used to analyze claims for errors before submission is called a(n):
A. claim scrubber.
B. claim edits.
C. claim cleaner.
D. claim reviewer.
E. claim adjuster.
31. Claim scrubbers are used by payers to examine claims before adjudicating them.
A. True
B. False
32. A delay imposed by Medicare intermediaries and some other health plans in paying claims is
called a payment floor.
A. True
B. False
33. The payment floor for electronic claims is:
A. 24 hours.
B. 48 hours.
C. 10 days.
D. 14 days.
E. 29 days.
34. The payment floor for paper claims is:
A. 24 hours.
B. 48 hours.
C. 10 days.
D. 14 days.
E. 29 days.
35. Uncollected money owed during the billing process is called:
A. accounts receivable.
B. accounts payable.
C. unremitted accounts.
D. outstanding payments.
E. billed receivables.
36. A claim is sent to the secondary insurance:
A. at the same time it is sent to the primary.
B. before it is sent to the primary.
C. after the claim is paid by the primary.
D. All of the above
E. None of the above
37. Payment may be denied by the payer because:
A. additional documentation may be needed.
B. the service was not covered by the plan.
C. a coding error was found.
D. All of the above
E. None of the above
38. For every claim that is filed, a provider will receive a(n):
A. EOB.
B. request for information.
C. payment.
D. All of the above
E. None of the above
39. The remittance information from the payers can be automatically posted by using a(n)
electronic remittance advice system.
A. True
B. False
40. To determine insurance eligibility or coverage, providers send an eligibility inquiry using the:
A. ANSI 270.
B. ANSI 271.
C. ANSI 278.
D. ANSI 835.
E. ANSI 837.
41. After a provider sends an eligibility request, a response is received from the payer using the:
A. ANSI 270 transaction.
B. ANSI 271 transaction.
C. ANSI 278 transaction.
D. ANSI 835 transaction.
E. ANSI 837 transaction.
42. The ________ is used to send the request for authorization and for the plan to return
information about the authorization, certification, or referral to the provider.
A. ANSI 270
B. ANSI 271
C. ANSI 278
D. ANSI 835
E. ANSI 837
43. The referral certification and authorization process can be conducted electronically by using
the:
A. Health Care Services Request for Review and Response.
B. Health Care Claim Status Request.
C. Additional Patient Information in Support of a Health Claim or Encounter.
D. Eligibility Benefit Inquiry and Response.
E. Claim Status Inquiry and Response.
44. When a plan asks for further information, supporting documentation, or test results, the
claim becomes a(n):
A. claim attachment.
B. claim edit.
C. invalid claim.
D. suspended claim.
E. rejected claim.
45. Claims that have NOT been paid in a reasonable period of time must be investigated by:
A. calling the plan help lines.
B. using the plan’s automated voice response system.
C. sending a Health Care Claim Status Request.
D. entering data on a web page provided by the plan.
E. All of the above
46. Which of the following is a supplemental document that provides additional medical
information that cannot be sent within the claim format?
A. Claim attachment
B. Claim edit
C. Claim scrubber
D. Claim documentation
E. Claim remittance
47. A(n) ________ is an example of a common attachment to a claim.
A. operative report
B. discharge summary
C. certificate of medical necessity
D. laboratory report
E. All of the above
48. The claim attachment standard became official in January of 2009.
A. True
B. False
49. Notice of Proposed Rule Making defines all of the following types of electronic claims
attachments EXCEPT:
A. emergency department reports.
B. laboratory reports.
C. clinical reports.
D. eligibility reports.
E. ambulance services.
50. In situations that providers know will require an attachment, the ANSI ________ may be
submitted along with the ANSI 837.
A. 270
B. 271
C. 275
D. 276
E. 835