HIMT-1135 Final Study Guide Overview
Exam UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS
Data - CORRECT ANSWER dates, numbers, symbols, images
Information - CORRECT ANSWER data that has been converted to a form that can be
used for a specific purpose
Knowledge - CORRECT ANSWER information with context, experience, &
interpretation
Secondary Data Source - CORRECT ANSWER Various databases & registries in a
healthcare setting (disease, trauma, cancer)
Unstructured Data - CORRECT ANSWER An EKG tracing, ultrasound video, and
transcribed reports
UHDDS - CORRECT ANSWER Uniform Hospital Discharge Data Set, the minimum
core collected on every inpatient discharged from a short‐term general hospital
Personal Identification Data - CORRECT ANSWER Captured in the UHDDS, includes
DOB, Sex, Race / Ethnicity, Address, Hospital ID, Admission date, Type of admission,
Discharge date, Physician ID, Principal diagnosis, Other diagnoses, Procedures & Dates,
Disposition of Patient, Total charges
Data Integrity - CORRECT ANSWER term used to describe complete, accurate, and
valid data or high‐quality data
Vital Statistics - CORRECT ANSWER includes data collected for vital events in our
lives (birth & adoptions, marriages, divorces, deaths & fetal deaths)
,Information Governance - CORRECT ANSWER the processes, roles, standards, &
metrics that ensure effective & efficient use of information in enabling an organization to
achieve its goals
Quality Data Consistency - CORRECT ANSWER characteristic of quality data
facilitated by clear understanding of data meanings and acceptable values, as well as
standardizing data collection procedures
Accuracy - CORRECT ANSWER If the medical record number is duplicated, there
may be inaccuracies from one version to the next that could potentially complicate treatment
Completeness - CORRECT ANSWER If the information captured in the record is
incomplete, it may affect billing
Volume - CORRECT ANSWER the ever‐growing amount of data available from
electronic systems and devices, such as the EHR, mobile devices, wearable devices, etc.
Velocity - CORRECT ANSWER the mobility of data (i.e., data coming in to and going
out of an organization)
Variety - CORRECT ANSWER the expansion of data from previously being primarily
structured to large amounts of unstructured data
Veracity - CORRECT ANSWER the 'trustworthiness' of data generated from many
sources and devices
Disposition - CORRECT ANSWER the AHIMA information governance principle
which insures the legal and ethical destruction and transfer of records
, Conditions of Participation - CORRECT ANSWER Provisions that must be met
through a written agreement if Hospital A is relying on the credentialing & privileging
decision made by Hospital B for a physician providing telemedicine
Distant-Site Telemedicine Facility - CORRECT ANSWER A facility that does not
participate in the Medicare program
Conditions of Participation - CORRECT ANSWER A set of regulations that govern the
documentation and retention of medical records.
History of physical examination - CORRECT ANSWER Must be documented in the
health record no more than 30 days before or 24 hours after admission to a hospital.
Retention period for medical records - CORRECT ANSWER Medical records must be
retained in their original or legally reproduced form for a period of 5 years.
Contents of medical records - CORRECT ANSWER Must contain admitting diagnosis,
consultations, complications, hospital acquired infections, unfavorable drug reactions,
informed consents, nursing notes, reports of treatment, medication records, radiology,
laboratory results, and vital signs.
Verbal orders - CORRECT ANSWER Must be dated, timed, and authenticated by the
ordering physician.
Pre-printed and standing orders - CORRECT ANSWER Permitted by the Conditions of
Participation.
Completion of medical records - CORRECT ANSWER Must be completed within 30
days following discharge.
Authentication of health records - CORRECT ANSWER By signature of the person
documenting in the medical record (electronic signature, written signature, key/PIN).
Exam UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS
Data - CORRECT ANSWER dates, numbers, symbols, images
Information - CORRECT ANSWER data that has been converted to a form that can be
used for a specific purpose
Knowledge - CORRECT ANSWER information with context, experience, &
interpretation
Secondary Data Source - CORRECT ANSWER Various databases & registries in a
healthcare setting (disease, trauma, cancer)
Unstructured Data - CORRECT ANSWER An EKG tracing, ultrasound video, and
transcribed reports
UHDDS - CORRECT ANSWER Uniform Hospital Discharge Data Set, the minimum
core collected on every inpatient discharged from a short‐term general hospital
Personal Identification Data - CORRECT ANSWER Captured in the UHDDS, includes
DOB, Sex, Race / Ethnicity, Address, Hospital ID, Admission date, Type of admission,
Discharge date, Physician ID, Principal diagnosis, Other diagnoses, Procedures & Dates,
Disposition of Patient, Total charges
Data Integrity - CORRECT ANSWER term used to describe complete, accurate, and
valid data or high‐quality data
Vital Statistics - CORRECT ANSWER includes data collected for vital events in our
lives (birth & adoptions, marriages, divorces, deaths & fetal deaths)
,Information Governance - CORRECT ANSWER the processes, roles, standards, &
metrics that ensure effective & efficient use of information in enabling an organization to
achieve its goals
Quality Data Consistency - CORRECT ANSWER characteristic of quality data
facilitated by clear understanding of data meanings and acceptable values, as well as
standardizing data collection procedures
Accuracy - CORRECT ANSWER If the medical record number is duplicated, there
may be inaccuracies from one version to the next that could potentially complicate treatment
Completeness - CORRECT ANSWER If the information captured in the record is
incomplete, it may affect billing
Volume - CORRECT ANSWER the ever‐growing amount of data available from
electronic systems and devices, such as the EHR, mobile devices, wearable devices, etc.
Velocity - CORRECT ANSWER the mobility of data (i.e., data coming in to and going
out of an organization)
Variety - CORRECT ANSWER the expansion of data from previously being primarily
structured to large amounts of unstructured data
Veracity - CORRECT ANSWER the 'trustworthiness' of data generated from many
sources and devices
Disposition - CORRECT ANSWER the AHIMA information governance principle
which insures the legal and ethical destruction and transfer of records
, Conditions of Participation - CORRECT ANSWER Provisions that must be met
through a written agreement if Hospital A is relying on the credentialing & privileging
decision made by Hospital B for a physician providing telemedicine
Distant-Site Telemedicine Facility - CORRECT ANSWER A facility that does not
participate in the Medicare program
Conditions of Participation - CORRECT ANSWER A set of regulations that govern the
documentation and retention of medical records.
History of physical examination - CORRECT ANSWER Must be documented in the
health record no more than 30 days before or 24 hours after admission to a hospital.
Retention period for medical records - CORRECT ANSWER Medical records must be
retained in their original or legally reproduced form for a period of 5 years.
Contents of medical records - CORRECT ANSWER Must contain admitting diagnosis,
consultations, complications, hospital acquired infections, unfavorable drug reactions,
informed consents, nursing notes, reports of treatment, medication records, radiology,
laboratory results, and vital signs.
Verbal orders - CORRECT ANSWER Must be dated, timed, and authenticated by the
ordering physician.
Pre-printed and standing orders - CORRECT ANSWER Permitted by the Conditions of
Participation.
Completion of medical records - CORRECT ANSWER Must be completed within 30
days following discharge.
Authentication of health records - CORRECT ANSWER By signature of the person
documenting in the medical record (electronic signature, written signature, key/PIN).
