HIM 1000-TEST 2 EXAM QUESTIONS
AND ANSWERS GRADED A+ 2026
Signature legend - ANS Ms. Smith analyzes patient records for deficiencies and determines
that there are entries that have been authenticated using initials. She needs to identify the
author of these entries to clarify information. She should reference the ____ to determine the
full name of the author of the entries.
False - ANS Medicare Conditions of Participation require hospitals to retain medical records
for a period of no less than five years.
True - ANS Health care providers are responsible for documenting care and treatment to
prove that patient care was provided.
True - ANS The primary purpose of the patient record is to provide continuity of care.
jacket film - ANS The HIM manager at Sunny View Hospital has decided that all records over
two years old will be microfilmed and that each patient record should be stored individually
after microfilming. This can be accomplished by using
A note was entered in the patient record stating that an incident report was completed.
A copy of the incident report was filed in the patient's record. - ANS Tom Smith, a patient at
Sunny View Hospital, fell out of his bed during his inpatient admission. At the time of the fall an
incident report was completed. He is now suing the hospital because he feels that the nurses
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 1
, were negligent when caring for him. The following actions were taken by the facility. Determine
which of these actions should NOT have occurred.
countersignature - ANS A form of authentication by an individual in addition to the signature
by the original author is known as a(n)
audit trail - ANS Sunny Valley Hospital has an electronic health record system. The health
information management (HIM) department has been asked by the quality management
department to monitor the number of times that providers make corrections in patient
documentation. Which of the following would provide information that can be used by the HIM
department to monitor the electronic record transactions?
provisional diagnosis - ANS An admission clerk must obtain the reason for the admission
when processing a hospital inpatient; this is called the:
the total number of discharges in the period - ANS To calculate the delinquent record rate,
divide the total number of delinquent records by:
True - ANS A patient record serves as a business record for the patient encounter and
contains administrative and clinical data.
every hour - ANS The abbreviation q.h. means:
true - ANS A signature legend identifies the author of a record entry by full signature when
initials are used in the patient record.
problem list - ANS Problem Number Diagnosis Date of Onset Date Resolved
1 Hypertension 12/05/XX
2 Diabetes 1/3/XX
3 Urinary Tract Infection 2/25/XX 3/10/XX
4 Respiratory Infection 4/5/XX 4/15/XX
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 2
AND ANSWERS GRADED A+ 2026
Signature legend - ANS Ms. Smith analyzes patient records for deficiencies and determines
that there are entries that have been authenticated using initials. She needs to identify the
author of these entries to clarify information. She should reference the ____ to determine the
full name of the author of the entries.
False - ANS Medicare Conditions of Participation require hospitals to retain medical records
for a period of no less than five years.
True - ANS Health care providers are responsible for documenting care and treatment to
prove that patient care was provided.
True - ANS The primary purpose of the patient record is to provide continuity of care.
jacket film - ANS The HIM manager at Sunny View Hospital has decided that all records over
two years old will be microfilmed and that each patient record should be stored individually
after microfilming. This can be accomplished by using
A note was entered in the patient record stating that an incident report was completed.
A copy of the incident report was filed in the patient's record. - ANS Tom Smith, a patient at
Sunny View Hospital, fell out of his bed during his inpatient admission. At the time of the fall an
incident report was completed. He is now suing the hospital because he feels that the nurses
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 1
, were negligent when caring for him. The following actions were taken by the facility. Determine
which of these actions should NOT have occurred.
countersignature - ANS A form of authentication by an individual in addition to the signature
by the original author is known as a(n)
audit trail - ANS Sunny Valley Hospital has an electronic health record system. The health
information management (HIM) department has been asked by the quality management
department to monitor the number of times that providers make corrections in patient
documentation. Which of the following would provide information that can be used by the HIM
department to monitor the electronic record transactions?
provisional diagnosis - ANS An admission clerk must obtain the reason for the admission
when processing a hospital inpatient; this is called the:
the total number of discharges in the period - ANS To calculate the delinquent record rate,
divide the total number of delinquent records by:
True - ANS A patient record serves as a business record for the patient encounter and
contains administrative and clinical data.
every hour - ANS The abbreviation q.h. means:
true - ANS A signature legend identifies the author of a record entry by full signature when
initials are used in the patient record.
problem list - ANS Problem Number Diagnosis Date of Onset Date Resolved
1 Hypertension 12/05/XX
2 Diabetes 1/3/XX
3 Urinary Tract Infection 2/25/XX 3/10/XX
4 Respiratory Infection 4/5/XX 4/15/XX
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 2
