Exam Toolkit Questions with
Accurate and Complete Solutions
Latest Update 2024
Principle of Retention - is the correct answer to An organization shall maintain its
information for an appropriate time, taking into account its legal, regulatory, fiscal,
operational, and historical requirements
Principle of Disposition - is the correct answer to An organization shall provide secure
and appropriate disposition for information no longer required to be maintained by
applicable laws and the organization's policies.
Transparency - is the correct answer to Communication, informing, sharing
information, decreasing mistrust, decreasing miscommunication, improving
communication
Integrity - is the correct answer to Accurate data, data is what it's supposed to be
Protection - is the correct answer to Data security, preventing violations or breaches,
correcting violations or breaches
Compliance - is the correct answer to Taking action to meet a requirement, law,
mandate, regulation, policy
Availability - is the correct answer to Medical record/EHR is accessible when needed
Retention - is the correct answer to Time, when, how long the record is kept
,Disposition - is the correct answer to Location, where is the record going to be
destroyed, record going to storage
Accuracy - is the correct answer to Error free
Accessibility - is the correct answer to Available when needed
Comprehensiveness - is the correct answer to All data is present, all medical record
documents are complete
Definition - is the correct answer to Data dictionary
Granularity - is the correct answer to Can't be further subdivided (1 patient =1 unit)
Precision - is the correct answer to Numerical data (size, weight, measurement)
Relevancy - is the correct answer to Is the data important right now, is data useful for
current patient encounter
Timeliness - is the correct answer to Action that meets a time requirement has to be
completed within a certain timeframe (H&P completed within 24 hours of enrollment)
Scheduling - is the correct answer to Which component of the patient portal is the
ability to see a dr's availability?
Medication history - is the correct answer to Where would information about the
patient's insulin dosage be found within the portal?
Closed record review - is the correct answer to Form of review conducted following
discharge of a patient from an acute care facility to obtain information about trends and
patterns of documentation?
,Terminal digit fling system - is the correct answer to A hospital uses a filing system for
permanent storage of paper based records. The records are filed according to a three
part number according to a three part number made of two digit parts. What type of
system is this?
Discharge orders - is the correct answer to A patient went to the emergency room
complaining of chest pain and was released home 4 hours later. Which type of
documentation is required in this scenario?
30 days 24 hours - is the correct answer to Within how many days prior to admission
must the H&P be performed and within how many hours must the H&P be placed in the
patient's record after admission?
A doctor should issue the order in writing - is the correct answer to A patient is ready
to leave the emergency room but will need discharge orders before leaving. How should
the discharge orders be communicated to this patient?
History and physical - is the correct answer to Which component of the medical record
does CMS CoP require to be completed no more than 30 days before or 24 hours after
admission?
Informed consent - is the correct answer to Which type of consent is a patient asked
to sign prior to undergoing a scheduled gallbladder surgery?
Medication administration record (MAR) - is the correct answer to Where does a
nurse document that a patient is given an oral dose of Coumadin 1 mg while
hospitalized?
Patient - is the correct answer to Which person's signature must be included in a
consent form?
CMS-1500 - is the correct answer to In a physician's practice, a doctor is attempting to
submit a claim to MCR, but the system is experiencing an outage. Which form would
this doctor use to submit a paper claim?
, Which guideline should an HIM professional use for documentation of both paper and
electronic records? - is the correct answer to The original documents should be
maintained in the health record
Which type of information can be found in a physician's order? - is the correct answer
to Written or verbal requests for treatment, tests, procedures, and medications
HCPCS - is the correct answer to Healthcare Common Procedure Coding System
-Claim reimbursement
Morphology - is the correct answer to Refers to the size of a tumor
FDA - is the correct answer to Developed NDC
IHTSDO - is the correct answer to International Health Terminology Standards
Development Organization
-Owns SNOMED-CT
Concepts - is the correct answer to Most granular unit in terminology
Mapping - is the correct answer to Reuse of data for another purpose
CPT - is the correct answer to Current Procedural Terminology
-Outpatient setting
Standards - is the correct answer to HCO accreditation
1996 - is the correct answer to What year was HIPAA enacted?