Certification of Fundamentals of HIM:
AHIMA Practice Questions Domain 1
2025-2026
A core data set developed by ASTM to communicate a patient's past and current health information as
the patient transitions from one care setting to another is:
A) Ambulatory Care Data Set
B) Continuity of care record
C) Minimum Data Set
D) Uniform Hospital Discharge Data Set - CORRECT ANSWER -A core data set developed by ASTM to
communicate a patient's past and current health information as the patient transitions from one care
setting to another is:
B) Continuity of Care Record
(The continuity of care record (CCR) standard (ASTM E2369-05) is a core data set of relevant
administrative, demographic, and clinical information elements about a patient's health status and
healthcare treatment. It was created to help communicate that information from one provider to
another for referral, transfer, or discharge of the patient.)
A crucial early step in designing an electronic health record (EHR) is to develop a(n) _____ in which the
characteristics of each data element are defined.
A) Accreditation manual
B) Core content
C) Continuity of care record
,D) Data dictionary - CORRECT ANSWER -A crucial early step in designing an electronic health record
(EHR) is to develop a(n) _____ in which the characteristics of each data element are defined.
D) Data dictionary
(A data dictionary improves data validity and reliability within, across, and outside the enterprise
because it ensures that each piece of data can only mean one thing. A critical early step in implementing
the EHR is to develop a data dictionary.)
A health information technician is responsible for designing a data collection form to collect data on
patients in an acute-care hospital. The first resource that she should use is:
A) ORYX
B) UACDS
C) MDS
D) UHDDS - CORRECT ANSWER -A health information technician is responsible for designing a data
collection form to collect data on patients in an acute-care hospital. The first resource that she should
use is:
D) UHDDS
(The purpose of the UHDDS is to list and define a set of common, uniform data elements. The data
elements are collected from the health records of every hospital inpatient and later abstracted from the
health record and included in national databases.)
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin
reactions. She says she is following her diabetic diet." In which part of a problem-oriented health record
progress note would this be written?
A) Subjective
B) Objective
C) Assessment
D) Plan - CORRECT ANSWER -A notation for a diabetic patient in a physician progress note reads:
"Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet." In which part
of a problem-oriented health record progress note would this be written?
A) Subjective
(Some providers also use SOAP format for their problem-oriented progress notes. A subjective (S) entry
relates significant information in the patient's words or from the patient's point of view.)
, A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood
pressure adequately controlled." In which part of a problem-oriented health record progress note would
this be written?
A) Assessment
B) Objective
C) Plan
D) Subjective - CORRECT ANSWER -A notation for a hypertensive patient in a physician ambulatory care
progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health
record progress note would this be written?
A) Assessment
(Some providers also use SOAP format for their problem-oriented progress notes. Professional
conclusions reached from evaluation of the subjective or objective information make up the
assessment.)
A nurse is responsible for which of the following types of acute-care documentation?
A) Medication administration record
B) Radiology report
C) Operative report
D) Therapy assessment - CORRECT ANSWER -A nurse is responsible for which of the following types of
acute-care documentation?
A) Medication administration record
(Nurses maintain chronological records of a patient's vital signs (blood pressure, heart rate, respiration
rate, and temperature) and separate logs that show what medications were ordered and when they
were administered on the medication administration record (MAR).)
A physician is reviewing lab results on a patient in his office. The EHR screen displays one set of results in
red with a flashing asterisk and also shows that this result is three times higher than the expected value.
This is an example of a(n) _____.
A) Alert
B) Reminder
C) Structured data
AHIMA Practice Questions Domain 1
2025-2026
A core data set developed by ASTM to communicate a patient's past and current health information as
the patient transitions from one care setting to another is:
A) Ambulatory Care Data Set
B) Continuity of care record
C) Minimum Data Set
D) Uniform Hospital Discharge Data Set - CORRECT ANSWER -A core data set developed by ASTM to
communicate a patient's past and current health information as the patient transitions from one care
setting to another is:
B) Continuity of Care Record
(The continuity of care record (CCR) standard (ASTM E2369-05) is a core data set of relevant
administrative, demographic, and clinical information elements about a patient's health status and
healthcare treatment. It was created to help communicate that information from one provider to
another for referral, transfer, or discharge of the patient.)
A crucial early step in designing an electronic health record (EHR) is to develop a(n) _____ in which the
characteristics of each data element are defined.
A) Accreditation manual
B) Core content
C) Continuity of care record
,D) Data dictionary - CORRECT ANSWER -A crucial early step in designing an electronic health record
(EHR) is to develop a(n) _____ in which the characteristics of each data element are defined.
D) Data dictionary
(A data dictionary improves data validity and reliability within, across, and outside the enterprise
because it ensures that each piece of data can only mean one thing. A critical early step in implementing
the EHR is to develop a data dictionary.)
A health information technician is responsible for designing a data collection form to collect data on
patients in an acute-care hospital. The first resource that she should use is:
A) ORYX
B) UACDS
C) MDS
D) UHDDS - CORRECT ANSWER -A health information technician is responsible for designing a data
collection form to collect data on patients in an acute-care hospital. The first resource that she should
use is:
D) UHDDS
(The purpose of the UHDDS is to list and define a set of common, uniform data elements. The data
elements are collected from the health records of every hospital inpatient and later abstracted from the
health record and included in national databases.)
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin
reactions. She says she is following her diabetic diet." In which part of a problem-oriented health record
progress note would this be written?
A) Subjective
B) Objective
C) Assessment
D) Plan - CORRECT ANSWER -A notation for a diabetic patient in a physician progress note reads:
"Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet." In which part
of a problem-oriented health record progress note would this be written?
A) Subjective
(Some providers also use SOAP format for their problem-oriented progress notes. A subjective (S) entry
relates significant information in the patient's words or from the patient's point of view.)
, A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood
pressure adequately controlled." In which part of a problem-oriented health record progress note would
this be written?
A) Assessment
B) Objective
C) Plan
D) Subjective - CORRECT ANSWER -A notation for a hypertensive patient in a physician ambulatory care
progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health
record progress note would this be written?
A) Assessment
(Some providers also use SOAP format for their problem-oriented progress notes. Professional
conclusions reached from evaluation of the subjective or objective information make up the
assessment.)
A nurse is responsible for which of the following types of acute-care documentation?
A) Medication administration record
B) Radiology report
C) Operative report
D) Therapy assessment - CORRECT ANSWER -A nurse is responsible for which of the following types of
acute-care documentation?
A) Medication administration record
(Nurses maintain chronological records of a patient's vital signs (blood pressure, heart rate, respiration
rate, and temperature) and separate logs that show what medications were ordered and when they
were administered on the medication administration record (MAR).)
A physician is reviewing lab results on a patient in his office. The EHR screen displays one set of results in
red with a flashing asterisk and also shows that this result is three times higher than the expected value.
This is an example of a(n) _____.
A) Alert
B) Reminder
C) Structured data
