HIM CHAPTER 5 EXAM QUESTIONS
AND ANSWERS 100% PASS
In an electronic environment, changes to a patient's record should be tracked in:
a. A duplicate file
b. An audit trail
c. An exception file
d. Nowhere, electronic changes completely wipe out prior entries - ANS b. An audit trail
Which of the following is a detective control?
a. A coder reviews a record in order to assign a clinical code
b. The nursing supervisor reviews a chart to ensure that medication administration notes were
properly entered
c. The HIM department sends a physician a list of the physician's incomplete charts
d. A nurse alerts a physician that a patient is allergic to an ordered medication - ANS b. The
nursing supervisor reviews a chart to ensure that medication administration notes were
properly entered
Which of the following processes will not be performed for electronic health records?
a. Chart assembly
b. Error corrections
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, c. Retrospective review
d. Chart analysis - ANS a. Chart assembly
What is the most common problem associated with paper records that isn't found when
managing electronic health records?
a. Loose sheets management
b. Missing documentation
c. Disorganized patient records
d. Lack of documentation - ANS a. Loose sheets management
The data quality characteristic associated withe the capture of data concurrently with its
observation is - ANS timeliness
The data quality characteristic associated with the collection of data in its entirety is:
a. Validity
b. Reliability
c. Timeliness
d. Completeness - ANS d. Completeness
Upon review of a record, the analyst determines that the physician has not signed several
progress notes. This record fails to reflect the data quality characteristic of:
a. Accuracy
b. Timeliness
c. Completeness
d. Both b & c - ANS Both b & c
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AND ANSWERS 100% PASS
In an electronic environment, changes to a patient's record should be tracked in:
a. A duplicate file
b. An audit trail
c. An exception file
d. Nowhere, electronic changes completely wipe out prior entries - ANS b. An audit trail
Which of the following is a detective control?
a. A coder reviews a record in order to assign a clinical code
b. The nursing supervisor reviews a chart to ensure that medication administration notes were
properly entered
c. The HIM department sends a physician a list of the physician's incomplete charts
d. A nurse alerts a physician that a patient is allergic to an ordered medication - ANS b. The
nursing supervisor reviews a chart to ensure that medication administration notes were
properly entered
Which of the following processes will not be performed for electronic health records?
a. Chart assembly
b. Error corrections
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, c. Retrospective review
d. Chart analysis - ANS a. Chart assembly
What is the most common problem associated with paper records that isn't found when
managing electronic health records?
a. Loose sheets management
b. Missing documentation
c. Disorganized patient records
d. Lack of documentation - ANS a. Loose sheets management
The data quality characteristic associated withe the capture of data concurrently with its
observation is - ANS timeliness
The data quality characteristic associated with the collection of data in its entirety is:
a. Validity
b. Reliability
c. Timeliness
d. Completeness - ANS d. Completeness
Upon review of a record, the analyst determines that the physician has not signed several
progress notes. This record fails to reflect the data quality characteristic of:
a. Accuracy
b. Timeliness
c. Completeness
d. Both b & c - ANS Both b & c
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 10
