Health Data Content & Standards (HIM 1-4) Study Guide and Key Concepts

1) Master Patient Index (MPI)

The master patient index must, at a minimum, include sufficient information to:

A. Justify the patient’s hospital bill
B. Uniquely identify the patient
C. Summarize the patient’s complete medical history
D. List all physicians who have ever treated the patient

Answer: B
Why: The MPI’s core purpose is accurate patient identification and linking records to the correct person.

2) Appropriate physician query title

Query titles should not ask questions or offer answer options. Which is the best query title?

A. CHF active or inactive
B. CHF Type
C. CHF systolic or diastolic
D. CHF active or acute

Answer: B
Why: “CHF Type” is neutral and doesn’t lead or present choices.

3) Specialist who shares the documentation goal with coding staff

Improving specificity of clinical reports through a physician query is a documentation goal shared by the coding staff and which specialist?

A. Certified Health Data Analyst (CHDA)
B. CHPS
C. CTR
D. CDIP

Answer: D
Why: CDIP (Clinical Documentation Integrity Practitioner) focuses on improving clinical documentation quality.

4) Registry annual caseload

You have been asked to report the registry’s annual caseload to administration. The most efficient way to retrieve this is to use:

A. Follow-up files
B. Patient index
C. Accession register
D. Patient abstracts

Answer: C
Why: The accession register tracks cases entered into the registry (best for annual counts).

5) HIPAA covered entity

According to the HIPAA Privacy Rule, which is a covered entity?

A. Department of Health and Human Services
B. Health plans
C. Joint Commission
D. Office of Inspector General

Answer: B
Why: HIPAA covered entities include health plans, healthcare providers (that transmit HIPAA transactions), and clearinghouses.

6) Notice of Privacy Practices (NPP)

When should the patient receive a copy of the Notice of Privacy Practices?

A. Within 3 days after the initial appointment
B. Initial encounter
C. With any preappointment information
D. Facility is only required to publicly post the notice

Answer: B
Why: Patients should receive the NPP at the first service delivery/first encounter (and acknowledgment is requested).

7) SOAP progress note: “Subjective”

Using SOAP documentation, choose the subjective statement:

A. Adjust pain medication; begin physical therapy tomorrow
B. Patient states low back pain is as severe as it was on admission
C. Patient moving about very cautiously, appears to be in pain
D. Sciatica unimproved with hot pack therapy

Answer: B
Why: Subjective = what the patient reports (symptoms/feelings).

8) Inappropriate authentication

Which method of identifying authorship/authentication would be inappropriate in a patient’s record?

A. Identifiable initials of a nurse writing a nursing note
B. A unique identification code entered by the person making the report
C. Written signature of the provider of care
D. Delegated use of a computer key by a radiology secretary

Answer: D
Why: Authentication credentials must not be shared/delegated.

9) Record destruction documentation: EXCEPT

All of these details must be included in record destruction documentation EXCEPT:

A. Statement that records were destroyed in the normal course of business
B. Dates the patient had surgery
C. Method of destruction
D. Signature of individuals supervising/witnessing destruction

Answer: B
Why: Destruction logs track what/when/how/who, not clinical details like surgery dates.

10) Least likely found by retrospective quantitative analysis

Which item is least likely to be identified by a retrospective quantitative analysis?

A. Need for physician authentication of two verbal orders
B. Discrepancy between postoperative diagnosis and pathology diagnosis
C. X-ray report charted on the wrong record
D. Missing discharge summary

Answer: B
Why: Quantitative review checks presence/absence; diagnosis discrepancies are more qualitative.

11) Physical safeguard example

Which is an example of a physical safeguard?

A. Identifying a privacy officer
B. Dual authentication for login
C. Locking offices and file cabinets containing PHI
D. Audit controls

Answer: C
Why: Physical safeguards protect physical access to PHI (locks, secured areas).

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12) H&P exception

A complete H&P may not be required for a new admission when:
A. Stay is under 24 hours
B. Patient is readmitted within a year
C. A current, legible H&P from the physician office is available
D. Hospital course is uncomplicated

13) Drop-down values improve which data quality trait?

Using a dropdown for sex (male/female/unknown) improves:
A. Timeliness
B. Precision
C. Accessibility
D. Charge capture

14) HIPAA enforcement agency

HIPAA Privacy/Security Rule enforcement is led by:
A. FBI
B. Office for Civil Rights (OCR)
C. Recovery Audit Contractors
D. Office of Inspector General

15) CARF facility—least likely service

Which is least likely for a CARF-accredited facility?
A. Brain injury rehab
B. Vocational evaluation
C. Chronic pain management
D. Palliative care

16) CDS role analyzing trends/variances

A CDS looking for trends and variances acts as a(n):
A. Educator
B. Analyst
C. Ambassador
D. Registrar

17) Medicare CoPs—likely added item

Medicare CoPs suggest documentation of which item for the patient’s record?
A. Interval summary
B. Consultation note
C. Advance directive status
D. Pathology report

18) ER record item not typical in acute care record

Most typical in ER record but not acute care record:
A. Lab results
B. Physical findings
C. Time and means of arrival
D. Diagnostic imaging

19) HIPAA workforce member—EXCEPT

Who is least likely considered a workforce member?
A. Volunteer
B. Lab intern
C. Pharmacy trainee
D. Electrician (external service)

20) Form/screen design main driver

Best driver for designing new forms/views:
A. Needs of users
B. Medical staff bylaws
C. QIO standards
D. Federal Register

21) Missed insulin dose found during retrospective review

This is an example of:
A. Utilization review
B. Legal review
C. Qualitative analysis
D. Quantitative analysis

22) Best source for recent Medicare certification standards

Best resource for recent certification standards:
A. Hospital bylaws
B. CARF manual
C. Joint Commission manual
D. Federal Register

23) Verbal orders—first source to verify authorized recorders

To confirm who is authorized to take verbal orders, consult:
A. Policy and procedure manual
B. Federal Register
C. Consolidated manual for hospitals
D. Hospital medical staff bylaws/rules/regulations

24) Rehab accreditation standards best resource

Best resource for rehab facility voluntary accreditation standards:
A. CARF manual
B. Medical staff bylaws
C. Joint Commission manual
D. CoPs for rehab facilities

25) Where does this “hospital course + discharge plan” excerpt belong?

A summary of treatment, response, and discharge plan belongs in:
A. Admission note
B. Discharge summary
C. Physical exam
D. Lab report

26) AHIMA—when should a query be considered?

A query should be considered when documentation is:
A. Conflicting or unclear
B. Incomplete/ambiguous
C. Lacks clinical validation
D. All of the above

27) Best source for field names + security levels

To track field names and security levels for data elements, use:
A. Facility data dictionary
B. UHDDS
C. Glossary of healthcare terms
D. MDS

28) Inappropriate in a query

Which is inappropriate in a provider query?
A. Including ICD-10 codes/guidelines
B. Being direct but not leading
C. Adding an “unable to determine” option
D. Keeping tone neutral

29) Trauma registry—standard ED data set

To ensure comparable ED trauma data, review:
A. DEEDS
B. UHDDS
C. ORYX
D. MDS

30) Standard definitions for acute care data dictionary

Best resource for standard definitions commonly collected in acute care:
A. Federal Register
B. Conditions of Participation
C. UHDDS
D. MDS

31) Record delinquency—most serious month

Given delinquent records %: April 51%, May 43%, June 61%. Worst month:
A. April
B. May
C. June
D. Cannot determine

32) Registry annual caseload (same concept)

Most efficient tool to obtain annual cancer registry caseload:
A. Patient abstracts
B. Follow-up files
C. Accession register
D. Patient index

33) De-identification removal

Which must be removed during HIPAA de-identification?
A. Principal diagnosis code
B. Place of service code
C. Date of birth
D. Facility NPI

34) Newborn record qualitative checklist item (not adult)

Which is unique to newborn inpatient records?
A. Chief complaint
B. APGAR score
C. Condition on discharge
D. Arrival method/time

35) Essential physical exam data item

A key item typically documented in a physical exam is:
A. Chief complaint
B. General appearance
C. Subjective ROS
D. Family history

36) Problem-oriented record component for indexing

Which component helps index documentation across the record?
A. Database
B. Problem list
C. Initial plan
D. Progress notes

37) Primary data source for healthcare statistics

Which is a primary data source?
A. Disease index
B. MPI
C. Accession register
D. Health record

38) When can the original paper record leave the hospital?

Original paper record may be removed when:
A. Taken to physician office post-discharge
B. Sent with patient to LTC
C. Transferred to another hospital’s trauma ED with the patient
D. Taken to court in response to subpoena duces tecum

39) Patient Self-Determination Act (PSDA)

Under PSDA, evidence of advance directives:
A. Must be documented in the health record
B. Is optional and not documented
C. Requires attorney preparation
D. Requires doctor approval

40) Joint Commission accreditation is voluntary, and it is:

A. Done annually in every facility
B. Required for state licensure in all states
C. Often used to meet deemed-status/reimbursement requirements for some programs
D. Considered unnecessary by most facilities

41) Regional sharing of patient information

Accessing patient info from multiple organizations in a geographic region suggests:
A. Expert system
B. RHIO
C. CPOE
D. EDMS

42) Joint Commission—H&P timing for operative patients

Time requirement for operative patient H&P is:
A. No time requirement
B. Within 8 hours post-surgery
C. Within 24 hours of admission or prior to surgery
D. Within 24 hours after surgery only

43) Which is a consultation report?

A. Cardiologist’s opinion on surgical risk
B. Pathology tissue exam report
C. Radiology interpretation
D. Technical ECG tracing interpretation

44) Promoting community-wide health information exchange

You are promoting membership in a:
A. Data retrieval portal group
B. Continuum of care
C. Data warehouse
D. Regional health information organization

45) Qualitative review of surgical records checks for:

A. Severity of illness supports acute care
B. Quality of follow-up care
C. Infection occurred and treatment details
D. Presence of operative report elements (diagnosis, findings, specimens)

46) H&P completion standard meeting JC + Medicare CoPs

Recommended completion timeframe:
A. 12 hours after admission
B. 24 hours after admission or prior to surgery
C. 24 hours after admission only
D. 12 hours after admission or prior to surgery

47) Getting transfer information to outpatient scheduling system

Fastest source for transfer/service movement information:
A. Disease index
B. R-ADT system
C. Generic abstracting screens
D. Indicator monitoring program

48) External data threat example

Which is an external data threat?
A. Unlocked workstation
B. Intern viewing celebrity records
C. Malware/phishing to steal credentials
D. Poor password policy

49) Real-time documentation at point of care

Encouraging staff to document at time/location of service is:
A. Quantitative record review
B. Clinical pertinence review
C. Concurrent record analysis
D. Point-of-care documentation

50) OBRA 1987—core SNF assessment data set

Core assessment elements for SNF residents are collected using:
A. UHDDS
B. Uniform Ambulatory Core Data
C. MDS
D. Uniform Clinical Data Set