MIAMI PHI 2604 FINAL EXAM SCRIPT 2026
QUESTIONS WITH SOLUTIONS GRADED A+
◉ primary purpose of health record documentation is: Answer:
*continuity of patient care, serving as a means of communication
among all healthcare provider
*used to evaluate the adequacy and appropriateness of quality care
*provide clinical data for research and education
*support reimbursement
*medical necessity
*quality of care measures
*public reporting for services rendered by a healthcare entity
◉ incomplete documentation can result in: Answer: *lack of
accuracy
*the use of nonspecific and general codes
*can impact data integrity
*impact reimbursement
*presenting potential compliance risks
◉ expectation of the provider: Answer: provide legible, complete,
clear, consistent, precise, and reliable documentation of the patient's
, health history, present illness, and course of treatment; also are
expected to follow medical staff bylaws and assist in developing
documentation and query policies and procedures
◉ expectation of individuals performing the query: Answer: follow
their healthcare entity's internal policies related to documentation,
querying, coding, and compliance, keeping in mind that data
accuracy and integrity are fundamental HIM values
..."questions" should be initiated when there is conflicting,
incomplete, or ambiguous documentation in the health record or
additional information is needed for correct assignment of the POA
indicator
◉ permanence and retention of the completed query... Answer: is
not subject to health record retention guidelines; a provider's
response to a query CAN BE (not required) documented in the
progress note, discharge summary, or on the query form as a part of
the formal health record
◉ organizations and providers are expected to follow policies and
bylaws to: Answer: develop query policy and procedures
◉ query policies should/might include: Answer: *a statement
regarding timely response and consequences for noncompliance or
lack of response to
queries
QUESTIONS WITH SOLUTIONS GRADED A+
◉ primary purpose of health record documentation is: Answer:
*continuity of patient care, serving as a means of communication
among all healthcare provider
*used to evaluate the adequacy and appropriateness of quality care
*provide clinical data for research and education
*support reimbursement
*medical necessity
*quality of care measures
*public reporting for services rendered by a healthcare entity
◉ incomplete documentation can result in: Answer: *lack of
accuracy
*the use of nonspecific and general codes
*can impact data integrity
*impact reimbursement
*presenting potential compliance risks
◉ expectation of the provider: Answer: provide legible, complete,
clear, consistent, precise, and reliable documentation of the patient's
, health history, present illness, and course of treatment; also are
expected to follow medical staff bylaws and assist in developing
documentation and query policies and procedures
◉ expectation of individuals performing the query: Answer: follow
their healthcare entity's internal policies related to documentation,
querying, coding, and compliance, keeping in mind that data
accuracy and integrity are fundamental HIM values
..."questions" should be initiated when there is conflicting,
incomplete, or ambiguous documentation in the health record or
additional information is needed for correct assignment of the POA
indicator
◉ permanence and retention of the completed query... Answer: is
not subject to health record retention guidelines; a provider's
response to a query CAN BE (not required) documented in the
progress note, discharge summary, or on the query form as a part of
the formal health record
◉ organizations and providers are expected to follow policies and
bylaws to: Answer: develop query policy and procedures
◉ query policies should/might include: Answer: *a statement
regarding timely response and consequences for noncompliance or
lack of response to
queries
