HIMA 2300 PRG II EXAM QUESTIONS
AND ANSWERS GRADED A+ 2026
14. Discharge summary documentation must include
A. a detailed history of the patient
B. a note from social services or discharge planning
C. significant findings during hospitalization
D. correct codes for significant procedures - ANS C. significant findings during hospitalization
15. The performance of qualitative analysis is an important tool in ensuring data quality. These
reviews evaluate
A. quality of care through the use of pre-established criteria
B. adverse effects and contraindications of drugs utilized during hospitalization
C. potentially compensable events
D. completeness, adequacy, and quality of documentation - ANS D. completeness, adequacy,
and quality of documentation
16. Ultimate responsibility for the quality and completion of entries in patient health records
belongs to the
A. chief of staff
B. attending physician
C. HIM director
D. risk manager - ANS B. attending physician
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 1
,17. Quantitative and qualitative reviews performed on patient records by medical record
personnel in either a skilled nursing facility or inpatient psychiatric facility are generally in the
form of
A. retrospective deficiency analysis
B. special study audits
C. concurrent chart review
D. occurrence screening - ANS C. concurrent chart review
18. The foundation for communicating all patient care goals in long-term care settings is the
A. legal assessment
B. medical history
C. individualized patient care plan.
D. Uniform Hospital Discharge Data Set - ANS C. individualized patient care plan.
19. Which interdisciplinary committee is most likely to be charged with the responsibility for
monitoring trends in delinquent health record percentages?
A. Health Record Committee
B. Utilization Review Committee
C. Risk Management Committee
D. Joint Conference Committee - ANS A. Health Record Committee
20. A health record analyst needs to quickly compare all lab values during one hospitalization.
The paper-based health record format best suited for this purpose is
A. problem-oriented
B. source-oriented
C. reverse chronological
D. integrated - ANS B. source-oriented
21. In preparing your facility for initial accreditation by Joint Commission, you are trying to
improve the process of ongoing record review. All health record reviews are presently
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 2
, performed by a team of HIM department personnel. The committee meets quarterly and
reports to a Quality Management Committee. In reviewing Joint Commission standards, your
first recommended change is to
A. have more frequent committee meetings
B. have the committee report to the Executive Committee
C. have a physician perform all the reviews
D. provide for record reviews to be performed by an interdisciplinary team of care providers -
ANS D. provide for record reviews to be performed by an interdisciplinary team of care
providers
22. As the privacy officer of your facility, you have been charged with developing policies and
procedures for protecting the confidentiality and security of the clinical data collected in your
computerized system. One of the first steps you will take is to judge the value of information
processed by your system and classify it. Another step you will need to take is to
A. authorize access to information collected based on level of data sensitivity
B. prevent all non-clinicians' access to any confidential information in the system
C. establish firewalls to protect aggregate data collected within your facility
D. establish passwords for all customers, both internal and external, who request access to the
information in your system - ANS A. authorize access to information collected based on level
of data sensitivity
23. A qualitative review of a health record reveals that the history and physical for a patient
admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the
following statements regarding the history and physical is true in this situation? Completion and
charting of the H&P indicates
A. noncompliance with Joint Commission standards
B. compliance with Joint Commission standards
C. compliance with Medicare regulations
D. compliance with Joint Commission standards for nonsurgical patients - ANS A.
noncompliance with Joint Commission standards
24. As your acute care facility moves toward the adoption of an EHR, your planning committee
is trying to prioritize systems that will contribute to patient safety. Your physicians have
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 3
AND ANSWERS GRADED A+ 2026
14. Discharge summary documentation must include
A. a detailed history of the patient
B. a note from social services or discharge planning
C. significant findings during hospitalization
D. correct codes for significant procedures - ANS C. significant findings during hospitalization
15. The performance of qualitative analysis is an important tool in ensuring data quality. These
reviews evaluate
A. quality of care through the use of pre-established criteria
B. adverse effects and contraindications of drugs utilized during hospitalization
C. potentially compensable events
D. completeness, adequacy, and quality of documentation - ANS D. completeness, adequacy,
and quality of documentation
16. Ultimate responsibility for the quality and completion of entries in patient health records
belongs to the
A. chief of staff
B. attending physician
C. HIM director
D. risk manager - ANS B. attending physician
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 1
,17. Quantitative and qualitative reviews performed on patient records by medical record
personnel in either a skilled nursing facility or inpatient psychiatric facility are generally in the
form of
A. retrospective deficiency analysis
B. special study audits
C. concurrent chart review
D. occurrence screening - ANS C. concurrent chart review
18. The foundation for communicating all patient care goals in long-term care settings is the
A. legal assessment
B. medical history
C. individualized patient care plan.
D. Uniform Hospital Discharge Data Set - ANS C. individualized patient care plan.
19. Which interdisciplinary committee is most likely to be charged with the responsibility for
monitoring trends in delinquent health record percentages?
A. Health Record Committee
B. Utilization Review Committee
C. Risk Management Committee
D. Joint Conference Committee - ANS A. Health Record Committee
20. A health record analyst needs to quickly compare all lab values during one hospitalization.
The paper-based health record format best suited for this purpose is
A. problem-oriented
B. source-oriented
C. reverse chronological
D. integrated - ANS B. source-oriented
21. In preparing your facility for initial accreditation by Joint Commission, you are trying to
improve the process of ongoing record review. All health record reviews are presently
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 2
, performed by a team of HIM department personnel. The committee meets quarterly and
reports to a Quality Management Committee. In reviewing Joint Commission standards, your
first recommended change is to
A. have more frequent committee meetings
B. have the committee report to the Executive Committee
C. have a physician perform all the reviews
D. provide for record reviews to be performed by an interdisciplinary team of care providers -
ANS D. provide for record reviews to be performed by an interdisciplinary team of care
providers
22. As the privacy officer of your facility, you have been charged with developing policies and
procedures for protecting the confidentiality and security of the clinical data collected in your
computerized system. One of the first steps you will take is to judge the value of information
processed by your system and classify it. Another step you will need to take is to
A. authorize access to information collected based on level of data sensitivity
B. prevent all non-clinicians' access to any confidential information in the system
C. establish firewalls to protect aggregate data collected within your facility
D. establish passwords for all customers, both internal and external, who request access to the
information in your system - ANS A. authorize access to information collected based on level
of data sensitivity
23. A qualitative review of a health record reveals that the history and physical for a patient
admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the
following statements regarding the history and physical is true in this situation? Completion and
charting of the H&P indicates
A. noncompliance with Joint Commission standards
B. compliance with Joint Commission standards
C. compliance with Medicare regulations
D. compliance with Joint Commission standards for nonsurgical patients - ANS A.
noncompliance with Joint Commission standards
24. As your acute care facility moves toward the adoption of an EHR, your planning committee
is trying to prioritize systems that will contribute to patient safety. Your physicians have
@COPYRIGHT 2026/2027 ALLRIGHTS RESERVED 3
