HEALTH INFORMATION MANAGEMENT -
RECORDS & DOCUMENTATION PRACTICE
EXAM 2026 | VERIFIED Q&A | HIGH PASS RATE
HEALTH INFORMATION MANAGEMENT RECORDS & DOCUMENTATION
PRACTICE EXAM 2026 | VERIFIED Q&A | HIGH PASS RATE
This practice exam contains 300 carefully crafted questions designed to test your
mastery of Health Information Management Records & Documentation. Work through
each question independently before checking the CORRECT ANSWER and
RATIONALE to maximize your retention and exam readiness.
MULTIPLE CHOICE — SELECT THE BEST ANSWER
1. What is the primary purpose of a medical record?
A. To serve as a billing document for insurance companies
B. To provide a legal record of hospital ownership
C. To document patient care and serve as a communication tool among healthcare
providers
D. To track hospital staff performance
E. To record only surgical procedures performed on patients
CORRECT ANSWER: C. To document patient care and serve as a
communication tool among healthcare providers
RATIONALE: The primary purpose of a medical record is to document all aspects
of patient care and facilitate communication among healthcare providers, ensuring
continuity and quality of care.
2. Which organization is responsible for accrediting hospitals in the United
States?
A. Centers for Medicare & Medicaid Services (CMS)
B. American Health Information Management Association (AHIMA)
C. The Joint Commission (TJC)
,D. World Health Organization (WHO)
E. National Institutes of Health (NIH)
CORRECT ANSWER: C. The Joint Commission (TJC)
RATIONALE: The Joint Commission is the primary accrediting body for hospitals
in the United States, setting standards for quality and patient safety in healthcare
organizations.
3. What does the acronym EHR stand for?
A. Electronic Health Repository
B. Electronic Health Record
C. Enhanced Hospital Report
D. Electronic Hospital Registry
E. Encoded Health Resource
CORRECT ANSWER: B. Electronic Health Record
RATIONALE: EHR stands for Electronic Health Record, a digital version of a
patient's paper chart that is real-time, patient-centered, and makes information available
to authorized users.
4. Which of the following is NOT a component of a medical record?
A. Patient demographics
B. Physician's progress notes
C. Hospital financial statements
D. Discharge summary
E. Medication administration records
CORRECT ANSWER: C. Hospital financial statements
RATIONALE: Hospital financial statements are administrative documents and are
not part of the clinical medical record. Medical records contain clinical documentation
such as demographics, progress notes, discharge summaries, and medication records.
,5. The legal health record is best defined as:
A. Any document generated by a healthcare facility
B. Only records stored in electronic format
C. The subset of health information that is used to support patient care and may be
disclosed upon request
D. Records kept only by physicians
E. Financial documents maintained by the billing department
CORRECT ANSWER: C. The subset of health information that is used to
support patient care and may be disclosed upon request
RATIONALE: The legal health record is the designated set of health information
that is formally documented, maintained, and disclosed by a healthcare organization
upon request for legal or patient care purposes.
6. Which of the following best describes a problem-oriented medical record
(POMR)?
A. Records organized by date of service only
B. Records structured around the patient's identified problems with SOAP notes
C. Records maintained solely by nurses
D. Records used only in outpatient settings
E. Records organized alphabetically by diagnosis
CORRECT ANSWER: B. Records structured around the patient's identified
problems with SOAP notes
RATIONALE: The problem-oriented medical record (POMR), developed by Dr.
Lawrence Weed, organizes information around patient problems and uses the SOAP
format — Subjective, Objective, Assessment, and Plan.
7. What does SOAP stand for in clinical documentation?
A. Summary, Observation, Analysis, Plan
, B. Subjective, Objective, Assessment, Plan
C. System, Order, Analysis, Procedure
D. Subjective, Order, Assessment, Progress
E. Summary, Order, Action, Plan
CORRECT ANSWER: B. Subjective, Objective, Assessment, Plan
RATIONALE: SOAP is a method of documentation used by healthcare providers.
Subjective refers to the patient's reported symptoms, Objective to clinical findings,
Assessment to the diagnosis, and Plan to the treatment approach.
8. Which act primarily governs the privacy of patient health information in the
United States?
A. The Affordable Care Act (ACA)
B. The Health Insurance Portability and Accountability Act (HIPAA)
C. The Medicare Modernization Act
D. The Social Security Act
E. The Patient Safety Act
CORRECT ANSWER: B. The Health Insurance Portability and Accountability
Act (HIPAA)
RATIONALE: HIPAA, enacted in 1996, establishes national standards for the
protection of individually identifiable health information, governing how covered entities
handle patient privacy and data security.
9. What is the minimum retention period for medical records as recommended by
AHIMA for adults?
A. 3 years after last encounter
B. 5 years after last encounter
C. 10 years after the date of last encounter or until the patient reaches age 21
D. 20 years after last encounter
E. Indefinitely
RECORDS & DOCUMENTATION PRACTICE
EXAM 2026 | VERIFIED Q&A | HIGH PASS RATE
HEALTH INFORMATION MANAGEMENT RECORDS & DOCUMENTATION
PRACTICE EXAM 2026 | VERIFIED Q&A | HIGH PASS RATE
This practice exam contains 300 carefully crafted questions designed to test your
mastery of Health Information Management Records & Documentation. Work through
each question independently before checking the CORRECT ANSWER and
RATIONALE to maximize your retention and exam readiness.
MULTIPLE CHOICE — SELECT THE BEST ANSWER
1. What is the primary purpose of a medical record?
A. To serve as a billing document for insurance companies
B. To provide a legal record of hospital ownership
C. To document patient care and serve as a communication tool among healthcare
providers
D. To track hospital staff performance
E. To record only surgical procedures performed on patients
CORRECT ANSWER: C. To document patient care and serve as a
communication tool among healthcare providers
RATIONALE: The primary purpose of a medical record is to document all aspects
of patient care and facilitate communication among healthcare providers, ensuring
continuity and quality of care.
2. Which organization is responsible for accrediting hospitals in the United
States?
A. Centers for Medicare & Medicaid Services (CMS)
B. American Health Information Management Association (AHIMA)
C. The Joint Commission (TJC)
,D. World Health Organization (WHO)
E. National Institutes of Health (NIH)
CORRECT ANSWER: C. The Joint Commission (TJC)
RATIONALE: The Joint Commission is the primary accrediting body for hospitals
in the United States, setting standards for quality and patient safety in healthcare
organizations.
3. What does the acronym EHR stand for?
A. Electronic Health Repository
B. Electronic Health Record
C. Enhanced Hospital Report
D. Electronic Hospital Registry
E. Encoded Health Resource
CORRECT ANSWER: B. Electronic Health Record
RATIONALE: EHR stands for Electronic Health Record, a digital version of a
patient's paper chart that is real-time, patient-centered, and makes information available
to authorized users.
4. Which of the following is NOT a component of a medical record?
A. Patient demographics
B. Physician's progress notes
C. Hospital financial statements
D. Discharge summary
E. Medication administration records
CORRECT ANSWER: C. Hospital financial statements
RATIONALE: Hospital financial statements are administrative documents and are
not part of the clinical medical record. Medical records contain clinical documentation
such as demographics, progress notes, discharge summaries, and medication records.
,5. The legal health record is best defined as:
A. Any document generated by a healthcare facility
B. Only records stored in electronic format
C. The subset of health information that is used to support patient care and may be
disclosed upon request
D. Records kept only by physicians
E. Financial documents maintained by the billing department
CORRECT ANSWER: C. The subset of health information that is used to
support patient care and may be disclosed upon request
RATIONALE: The legal health record is the designated set of health information
that is formally documented, maintained, and disclosed by a healthcare organization
upon request for legal or patient care purposes.
6. Which of the following best describes a problem-oriented medical record
(POMR)?
A. Records organized by date of service only
B. Records structured around the patient's identified problems with SOAP notes
C. Records maintained solely by nurses
D. Records used only in outpatient settings
E. Records organized alphabetically by diagnosis
CORRECT ANSWER: B. Records structured around the patient's identified
problems with SOAP notes
RATIONALE: The problem-oriented medical record (POMR), developed by Dr.
Lawrence Weed, organizes information around patient problems and uses the SOAP
format — Subjective, Objective, Assessment, and Plan.
7. What does SOAP stand for in clinical documentation?
A. Summary, Observation, Analysis, Plan
, B. Subjective, Objective, Assessment, Plan
C. System, Order, Analysis, Procedure
D. Subjective, Order, Assessment, Progress
E. Summary, Order, Action, Plan
CORRECT ANSWER: B. Subjective, Objective, Assessment, Plan
RATIONALE: SOAP is a method of documentation used by healthcare providers.
Subjective refers to the patient's reported symptoms, Objective to clinical findings,
Assessment to the diagnosis, and Plan to the treatment approach.
8. Which act primarily governs the privacy of patient health information in the
United States?
A. The Affordable Care Act (ACA)
B. The Health Insurance Portability and Accountability Act (HIPAA)
C. The Medicare Modernization Act
D. The Social Security Act
E. The Patient Safety Act
CORRECT ANSWER: B. The Health Insurance Portability and Accountability
Act (HIPAA)
RATIONALE: HIPAA, enacted in 1996, establishes national standards for the
protection of individually identifiable health information, governing how covered entities
handle patient privacy and data security.
9. What is the minimum retention period for medical records as recommended by
AHIMA for adults?
A. 3 years after last encounter
B. 5 years after last encounter
C. 10 years after the date of last encounter or until the patient reaches age 21
D. 20 years after last encounter
E. Indefinitely
