CEHRS STUDY GUIDE 2026 EXAM QUESTIONS AND
ANSWERS GRADED A+
✔✔Discharge Summary - ✔✔Report written b y the provider when a patient is being
discharged from inpatient care; summarizes the patient's chief complaint or whey they
are were admitted to the hospital, diagnostic test results and other findings, treatments
administered and how the patient responded to them; outliners recommendations for
continued care and follow up, as well as dietary, medication and activity instructions; the
provider must sign the final copy in the record before the record can be marked
complete.
✔✔Electronic Health Record (EHR) - ✔✔While this term is generic, its use denotes a
system-wide record that involves inputs from many systems and is used across a
diverse environment of care with multiple location; although not strictly defined as such,
EHR often refers to the electronic records in a hospital or integrated health care delivery
system.
✔✔EHR technology - ✔✔Refers to the conceptual EHR, including the basic structure,
functionality, and expected outcomes users expect from any system identified as being
an electronic health or medical records system.
✔✔Electronic Medical Record (EMR) - ✔✔Another generic term for a digitized medical
record; this term has evolved to most often refer to the single, standalone records
systems that providers' offices and other smaller outpatient settings use; the term EMR
is most often used in reference to the electronic records used by providers in their
private practice and outpatient settings; many EMR's can exchange data with larger
hospital-based EHR systems through the use of a Continuity of Care Document (CCD)
✔✔Fully-integrated EHR - ✔✔Functionality that has replaced paper records entirely; few
hospitals or health care systems in the U.S. have achieved this yet, but many are
moving in this direction.
✔✔Health Information Management (HIM) department - ✔✔Department responsible for
the care and management of all patient information; as electronic records began to
replace paper-based records, HIM professionals became key players in the transition to
the EHR or EMR system; previously known as the medical records department.
✔✔Health Information Technology - ✔✔General use of computers and related devices
to manage the day-to-day functions in a health care environment.
✔✔Health Insurance Portability and Accountability ACT of 1996 (HIPAA) -
✔✔Addressing security and privacy protections for health care information.
✔✔HIPAA Privacy Rule - ✔✔Mandates the protection of patients' personal health
information by hospitals and health care facilities.
, ✔✔HIPAA Security Rule - ✔✔Sets forth the administrative, physical, and technical
safeguards for covered entities in order to protect the confidentiality, integrity, and
availability of PHI that is stored electronically.
✔✔History and Physical (H and P) - ✔✔Providers document a patient's history and
perform a physical exam when she presents for health care services.
✔✔Health Information Technology for Economic and Clinical Health (HITECH) -
✔✔Encourages the adoption and meaningful use of health information technology.
✔✔Hospital Information System (HIS) - ✔✔Collection of systems that collect, store, and
allow manipulation and management of data generated in the daily operations of a
facility.
✔✔International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-
CM) - ✔✔Coding and classification system that groups diseases, disorders, and
procedures into similar categories; there are three volumes in ICD-9-CM.
✔✔Information Technology (IT) Department - ✔✔The IT department in facilities has
emerged as a necessary response to the transition from a paper-based world to one
that increasingly reliant on technology.
✔✔Joint Commission on the Accreditation of Health Care Organizations - ✔✔Not-for-
profit and independent (non-governmental) organization that accredits and certifies
more than 19,000 health care facilities and programs in the U.S.
✔✔Legacy Information System - ✔✔Department-specific systems that pre-date the
implementation of EHRs by several decades; sometimes referred to as legacy systems.
✔✔Master Patient Index (MPI) - ✔✔Record of every patient who has been treated,
seen, or evaluated in a facility.
✔✔Meaningful Use - ✔✔Meaningful use is both a program and a definition; the
Meaningful Use program are the federal incentives established by CMS for facilities to
use EHR technology in a meaningful way; meaningful use, the definition, refers to using
EHR technology in a manner that makes a meaningful impact on patient care and
safety.
✔✔Medical Staff Committee - ✔✔A committee formed to discuss and recommend
practices, policies, and other activities specific to the medical staff.
ANSWERS GRADED A+
✔✔Discharge Summary - ✔✔Report written b y the provider when a patient is being
discharged from inpatient care; summarizes the patient's chief complaint or whey they
are were admitted to the hospital, diagnostic test results and other findings, treatments
administered and how the patient responded to them; outliners recommendations for
continued care and follow up, as well as dietary, medication and activity instructions; the
provider must sign the final copy in the record before the record can be marked
complete.
✔✔Electronic Health Record (EHR) - ✔✔While this term is generic, its use denotes a
system-wide record that involves inputs from many systems and is used across a
diverse environment of care with multiple location; although not strictly defined as such,
EHR often refers to the electronic records in a hospital or integrated health care delivery
system.
✔✔EHR technology - ✔✔Refers to the conceptual EHR, including the basic structure,
functionality, and expected outcomes users expect from any system identified as being
an electronic health or medical records system.
✔✔Electronic Medical Record (EMR) - ✔✔Another generic term for a digitized medical
record; this term has evolved to most often refer to the single, standalone records
systems that providers' offices and other smaller outpatient settings use; the term EMR
is most often used in reference to the electronic records used by providers in their
private practice and outpatient settings; many EMR's can exchange data with larger
hospital-based EHR systems through the use of a Continuity of Care Document (CCD)
✔✔Fully-integrated EHR - ✔✔Functionality that has replaced paper records entirely; few
hospitals or health care systems in the U.S. have achieved this yet, but many are
moving in this direction.
✔✔Health Information Management (HIM) department - ✔✔Department responsible for
the care and management of all patient information; as electronic records began to
replace paper-based records, HIM professionals became key players in the transition to
the EHR or EMR system; previously known as the medical records department.
✔✔Health Information Technology - ✔✔General use of computers and related devices
to manage the day-to-day functions in a health care environment.
✔✔Health Insurance Portability and Accountability ACT of 1996 (HIPAA) -
✔✔Addressing security and privacy protections for health care information.
✔✔HIPAA Privacy Rule - ✔✔Mandates the protection of patients' personal health
information by hospitals and health care facilities.
, ✔✔HIPAA Security Rule - ✔✔Sets forth the administrative, physical, and technical
safeguards for covered entities in order to protect the confidentiality, integrity, and
availability of PHI that is stored electronically.
✔✔History and Physical (H and P) - ✔✔Providers document a patient's history and
perform a physical exam when she presents for health care services.
✔✔Health Information Technology for Economic and Clinical Health (HITECH) -
✔✔Encourages the adoption and meaningful use of health information technology.
✔✔Hospital Information System (HIS) - ✔✔Collection of systems that collect, store, and
allow manipulation and management of data generated in the daily operations of a
facility.
✔✔International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-
CM) - ✔✔Coding and classification system that groups diseases, disorders, and
procedures into similar categories; there are three volumes in ICD-9-CM.
✔✔Information Technology (IT) Department - ✔✔The IT department in facilities has
emerged as a necessary response to the transition from a paper-based world to one
that increasingly reliant on technology.
✔✔Joint Commission on the Accreditation of Health Care Organizations - ✔✔Not-for-
profit and independent (non-governmental) organization that accredits and certifies
more than 19,000 health care facilities and programs in the U.S.
✔✔Legacy Information System - ✔✔Department-specific systems that pre-date the
implementation of EHRs by several decades; sometimes referred to as legacy systems.
✔✔Master Patient Index (MPI) - ✔✔Record of every patient who has been treated,
seen, or evaluated in a facility.
✔✔Meaningful Use - ✔✔Meaningful use is both a program and a definition; the
Meaningful Use program are the federal incentives established by CMS for facilities to
use EHR technology in a meaningful way; meaningful use, the definition, refers to using
EHR technology in a manner that makes a meaningful impact on patient care and
safety.
✔✔Medical Staff Committee - ✔✔A committee formed to discuss and recommend
practices, policies, and other activities specific to the medical staff.
