WGU HIT 215 — Health Information Management
WGU HIT 215: HEALTH INFORMATION MANAGEMENT EXAM READY -
VERIFIED QUESTIONS AND ANSWERS - COMPREHENSIVE LATEST
VERSION (2026/2027)
Q1. What is Health Information Management (HIM)?
ANSWER HIM is the practice of acquiring, analyzing, and protecting
digital and traditional medical information vital to providing quality patient
care. It bridges clinical care, operational management, and information
technology.
Q2. What organization awards the RHIA credential?
ANSWER The American Health Information Management Association
(AHIMA) awards the Registered Health Information Administrator (RHIA)
credential.
Q3. What does RHIT stand for and what does it signify?
ANSWER RHIT stands for Registered Health Information Technician. It
signifies competency in health data management and is awarded by
AHIMA after passing a credentialing exam.
Q4. What is the primary purpose of the medical record?
ANSWER The primary purpose is to document the patient's health
history, clinical findings, diagnoses, treatment, and outcomes to support
continuity of care and communication among providers.
Q5. Name the secondary purposes of the health record.
ANSWER Secondary purposes include legal documentation, billing
and reimbursement, quality improvement, research, education, public
health reporting, and planning.
Q6. What is a hybrid health record?
ANSWER A hybrid record contains both paper-based and electronic
components, where some portions of the patient record are in electronic
format and others remain on paper.
Q7. Define Electronic Health Record (EHR).
ANSWER An EHR is a real-time, patient-centered record that provides
immediate and secure information access to authorized users. It goes
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, WGU HIT 215 — Health Information Management
beyond data storage by including clinical decision support and
interoperability.
Q8. What is the difference between an EHR and an EMR?
ANSWER An EMR (Electronic Medical Record) is a digital version of a
paper chart within a single practice. An EHR is designed to share
information across multiple providers and organizations.
Q9. What is a Personal Health Record (PHR)?
ANSWER A PHR is an electronic application used by patients to
maintain and manage their own health information in a private, secure,
and confidential environment.
Q10. What does AHIMA stand for?
ANSWER American Health Information Management Association —
the premier professional organization for HIM professionals in the United
States.
Q11. What are the core HIM functions?
ANSWER Core functions include clinical data management, coding
and classification, health information access and disclosure, data quality
management, revenue cycle management, compliance, and informatics.
Q12. What is data governance in HIM?
ANSWER Data governance is the overall management of the
availability, usability, integrity, and security of data, ensuring data is
trustworthy and consistent across an organization.
Q13. What is chart deficiency?
ANSWER A chart deficiency is a missing or incomplete documentation
element in a health record, such as an unsigned order or missing
discharge summary.
Q14. What is a master patient index (MPI)?
ANSWER The MPI is a permanent database of all patients registered
in a healthcare facility, serving as the primary patient identifier and
linking all records to each unique patient.
Q15. What problems can arise from a poor MPI?
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, WGU HIT 215 — Health Information Management
ANSWER Duplicate records, overlays (merging two patients' data),
identity theft risks, incorrect patient matching, and compromised patient
safety.
Q16. What is the record retention schedule?
ANSWER A retention schedule specifies how long health records must
be kept. Federal law generally requires Medicare records to be retained
for 5 years; most states require adult records for 10 years from last
encounter.
Q17. What is the minimum necessary standard in HIM?
ANSWER Under HIPAA, only the minimum amount of PHI necessary
to accomplish the intended purpose should be used, disclosed, or
requested.
Q18. What is the difference between quantitative and qualitative
analysis of health records?
ANSWER Quantitative analysis checks for completeness (presence of
required documents/signatures). Qualitative analysis evaluates the
accuracy, consistency, and clinical adequacy of documentation.
Q19. What is concurrent record review?
ANSWER Concurrent review is the analysis of health records while the
patient is still admitted, allowing deficiencies to be corrected in real time.
Q20. What is retrospective record review?
ANSWER Retrospective review occurs after patient discharge,
identifying and resolving deficiencies after the fact.
Q21. Define "source-oriented" health records.
ANSWER Source-oriented records organize information by the source
of documentation (nursing notes together, physician notes together, lab
results together).
Q22. Define "problem-oriented" health records.
ANSWER Problem-oriented records organize documentation around
the patient's specific clinical problems, using SOAP notes (Subjective,
Objective, Assessment, Plan).
Q23. What is a discharge summary?
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, WGU HIT 215 — Health Information Management
ANSWER A discharge summary is a clinical document that
summarizes the reason for admission, key findings, treatments,
outcomes, and follow-up plan at the time the patient is discharged.
Q24. What is the H&P (History and Physical)?
ANSWER The H&P documents the patient's chief complaint, medical
history, review of systems, and physical examination findings, required
within 24 hours of admission.
Q25. What is an operative report?
ANSWER An operative report documents the description of the
surgical procedure performed, indications, techniques used, findings,
and the patient's condition.
Q26. What is a pathology report?
ANSWER A pathology report documents the macroscopic and
microscopic examination of tissue, cells, or body fluids to diagnose
disease.
Q27. What is an advance directive?
ANSWER An advance directive is a legal document expressing a
patient's wishes regarding medical treatment if they become unable to
make decisions, including living wills and durable power of attorney for
healthcare.
Q28. What is a care plan in the health record?
ANSWER A care plan is a documented, individualized plan outlining
goals, interventions, and outcomes for a patient's treatment,
coordinating the efforts of the healthcare team.
Q29. What are clinical practice guidelines?
ANSWER Clinical practice guidelines are systematically developed
statements that help practitioners and patients make decisions about
appropriate healthcare for specific clinical circumstances.
Q30. What is health informatics?
ANSWER Health informatics is the science of how to use data,
information, and knowledge to improve human health and the delivery of
healthcare services.
Q31. What is interoperability in HIM?
Page 4 of 39
WGU HIT 215: HEALTH INFORMATION MANAGEMENT EXAM READY -
VERIFIED QUESTIONS AND ANSWERS - COMPREHENSIVE LATEST
VERSION (2026/2027)
Q1. What is Health Information Management (HIM)?
ANSWER HIM is the practice of acquiring, analyzing, and protecting
digital and traditional medical information vital to providing quality patient
care. It bridges clinical care, operational management, and information
technology.
Q2. What organization awards the RHIA credential?
ANSWER The American Health Information Management Association
(AHIMA) awards the Registered Health Information Administrator (RHIA)
credential.
Q3. What does RHIT stand for and what does it signify?
ANSWER RHIT stands for Registered Health Information Technician. It
signifies competency in health data management and is awarded by
AHIMA after passing a credentialing exam.
Q4. What is the primary purpose of the medical record?
ANSWER The primary purpose is to document the patient's health
history, clinical findings, diagnoses, treatment, and outcomes to support
continuity of care and communication among providers.
Q5. Name the secondary purposes of the health record.
ANSWER Secondary purposes include legal documentation, billing
and reimbursement, quality improvement, research, education, public
health reporting, and planning.
Q6. What is a hybrid health record?
ANSWER A hybrid record contains both paper-based and electronic
components, where some portions of the patient record are in electronic
format and others remain on paper.
Q7. Define Electronic Health Record (EHR).
ANSWER An EHR is a real-time, patient-centered record that provides
immediate and secure information access to authorized users. It goes
Page 1 of 39
, WGU HIT 215 — Health Information Management
beyond data storage by including clinical decision support and
interoperability.
Q8. What is the difference between an EHR and an EMR?
ANSWER An EMR (Electronic Medical Record) is a digital version of a
paper chart within a single practice. An EHR is designed to share
information across multiple providers and organizations.
Q9. What is a Personal Health Record (PHR)?
ANSWER A PHR is an electronic application used by patients to
maintain and manage their own health information in a private, secure,
and confidential environment.
Q10. What does AHIMA stand for?
ANSWER American Health Information Management Association —
the premier professional organization for HIM professionals in the United
States.
Q11. What are the core HIM functions?
ANSWER Core functions include clinical data management, coding
and classification, health information access and disclosure, data quality
management, revenue cycle management, compliance, and informatics.
Q12. What is data governance in HIM?
ANSWER Data governance is the overall management of the
availability, usability, integrity, and security of data, ensuring data is
trustworthy and consistent across an organization.
Q13. What is chart deficiency?
ANSWER A chart deficiency is a missing or incomplete documentation
element in a health record, such as an unsigned order or missing
discharge summary.
Q14. What is a master patient index (MPI)?
ANSWER The MPI is a permanent database of all patients registered
in a healthcare facility, serving as the primary patient identifier and
linking all records to each unique patient.
Q15. What problems can arise from a poor MPI?
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, WGU HIT 215 — Health Information Management
ANSWER Duplicate records, overlays (merging two patients' data),
identity theft risks, incorrect patient matching, and compromised patient
safety.
Q16. What is the record retention schedule?
ANSWER A retention schedule specifies how long health records must
be kept. Federal law generally requires Medicare records to be retained
for 5 years; most states require adult records for 10 years from last
encounter.
Q17. What is the minimum necessary standard in HIM?
ANSWER Under HIPAA, only the minimum amount of PHI necessary
to accomplish the intended purpose should be used, disclosed, or
requested.
Q18. What is the difference between quantitative and qualitative
analysis of health records?
ANSWER Quantitative analysis checks for completeness (presence of
required documents/signatures). Qualitative analysis evaluates the
accuracy, consistency, and clinical adequacy of documentation.
Q19. What is concurrent record review?
ANSWER Concurrent review is the analysis of health records while the
patient is still admitted, allowing deficiencies to be corrected in real time.
Q20. What is retrospective record review?
ANSWER Retrospective review occurs after patient discharge,
identifying and resolving deficiencies after the fact.
Q21. Define "source-oriented" health records.
ANSWER Source-oriented records organize information by the source
of documentation (nursing notes together, physician notes together, lab
results together).
Q22. Define "problem-oriented" health records.
ANSWER Problem-oriented records organize documentation around
the patient's specific clinical problems, using SOAP notes (Subjective,
Objective, Assessment, Plan).
Q23. What is a discharge summary?
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, WGU HIT 215 — Health Information Management
ANSWER A discharge summary is a clinical document that
summarizes the reason for admission, key findings, treatments,
outcomes, and follow-up plan at the time the patient is discharged.
Q24. What is the H&P (History and Physical)?
ANSWER The H&P documents the patient's chief complaint, medical
history, review of systems, and physical examination findings, required
within 24 hours of admission.
Q25. What is an operative report?
ANSWER An operative report documents the description of the
surgical procedure performed, indications, techniques used, findings,
and the patient's condition.
Q26. What is a pathology report?
ANSWER A pathology report documents the macroscopic and
microscopic examination of tissue, cells, or body fluids to diagnose
disease.
Q27. What is an advance directive?
ANSWER An advance directive is a legal document expressing a
patient's wishes regarding medical treatment if they become unable to
make decisions, including living wills and durable power of attorney for
healthcare.
Q28. What is a care plan in the health record?
ANSWER A care plan is a documented, individualized plan outlining
goals, interventions, and outcomes for a patient's treatment,
coordinating the efforts of the healthcare team.
Q29. What are clinical practice guidelines?
ANSWER Clinical practice guidelines are systematically developed
statements that help practitioners and patients make decisions about
appropriate healthcare for specific clinical circumstances.
Q30. What is health informatics?
ANSWER Health informatics is the science of how to use data,
information, and knowledge to improve human health and the delivery of
healthcare services.
Q31. What is interoperability in HIM?
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