HCM 435 Midterm Test Questions with Correct Answers Latest Update 2025
What is the definition of health information according to HIPAA? - Answers Any information,
whether oral or recorded in any form or medium that is created or received by a health care
provider. Relates to the past, present, or future physical or mental health condition of an
individual
According to HIPAA, what determines if it is protected health information? - Answers
Information first must be identifiable, it must have an individual patient perspective and the
patient's identity must be known
What is the definition of EMR? - Answers health information on an individual that can be created,
gathered, managed, and consulted by authorized clinicians and staff within one healthcare
organization
What is the definition of EHR? - Answers health information on an individual that conforms to
nationally recognized interoperability standards and that can be created, managed, and
consulted by authorized clinicians and staff across more than one healthcare organization
What is the definition of personal health record? - Answers an electronic record of health
information on an individual that conforms to nationally recognized interoperability standards
and that can be drawn from multiple sources while being managed, shared, and controlled by
the individual
Name the various purposes of patient records - Answers Patient care, communication, legal
documentation, billing and reimbursement, research and quality management, and population
health
Differentiate between the two types of organizing the health record - Answers source-oriented-
diary-like, chronological format
and patient-oriented medical records (POMR)- created and organized around the patient's
problems, not the source of information
CMS 1500 - Answers is for submitting claims for health service providers
UB-04 - Answers is submitting claims for institutional providers such as hospitals
what are the major purposes of having uniform data sets? - Answers it means that data can be
compared not only within organizations but also within states and across the country.
What are the different uniform data sets and what type of health care organization will be using
that particular data set? - Answers UHDDS (Uniform Hospital Discharge Data Set)- Medicare and
Medicaid programs
ACDS (Uniform Ambulatory Care Data Set)- ambulatory and outpatient settings
, MDS (Minimum Data Set)- Long term care
What are the different types of comparative health care data sets and how might they be utilized?
- Answers Patient satisfaction- This is good for benchmarking and can help improve methods
so they can grow their business and keep consumers happy.
Practice Patterns- This can help improve practice patterns.
Health Plans- to help compare and pick the right one for you.
Clinical indicators- shows accreditation status and performance measures.
Population's measures- shows managers the demographics of the area.
What is the difference between data, information and knowledge and be able to distinguishes
the differences of each? - Answers Information is processed data.
Knowledge is defined as a combination of rules, relationships, ideas, and experiences.
Knowledge is the highest level in the hierarchy.
Poor quality data originates from two major areas. What are they? - Answers content and form
According to the Medical Record Institute, identify the 5 major functions negatively affected by
poor quality data. - Answers Patient Safety
Public Safety
Continuity of Patient Care
Health Care Economics
Clinical Research and Outcomes Analysis
What is the definition of information capture? - Answers is the process of recording
representations of human thought, perceptions, or actions in documenting patient care, as well
as device-generated information that is gathered and/or computed about a patient as part of
health care.
what is the definition of report generation? - Answers consists of the formatting and/or
structuring of captured information. It is the process of analyzing, organizing, and presenting
recorded patient information for authentication and inclusion in the patient's healthcare record.
What are the key principles developed by the MRI that should be adhered to in order to ensure
data quality? - Answers Unique patient identification must be assured within and across
healthcare documentation systems.
Healthcare documentation must be: accurate and consistent, complete, timely, interoperable
across types of documentation systems, accessible at any time and at any place where patient
What is the definition of health information according to HIPAA? - Answers Any information,
whether oral or recorded in any form or medium that is created or received by a health care
provider. Relates to the past, present, or future physical or mental health condition of an
individual
According to HIPAA, what determines if it is protected health information? - Answers
Information first must be identifiable, it must have an individual patient perspective and the
patient's identity must be known
What is the definition of EMR? - Answers health information on an individual that can be created,
gathered, managed, and consulted by authorized clinicians and staff within one healthcare
organization
What is the definition of EHR? - Answers health information on an individual that conforms to
nationally recognized interoperability standards and that can be created, managed, and
consulted by authorized clinicians and staff across more than one healthcare organization
What is the definition of personal health record? - Answers an electronic record of health
information on an individual that conforms to nationally recognized interoperability standards
and that can be drawn from multiple sources while being managed, shared, and controlled by
the individual
Name the various purposes of patient records - Answers Patient care, communication, legal
documentation, billing and reimbursement, research and quality management, and population
health
Differentiate between the two types of organizing the health record - Answers source-oriented-
diary-like, chronological format
and patient-oriented medical records (POMR)- created and organized around the patient's
problems, not the source of information
CMS 1500 - Answers is for submitting claims for health service providers
UB-04 - Answers is submitting claims for institutional providers such as hospitals
what are the major purposes of having uniform data sets? - Answers it means that data can be
compared not only within organizations but also within states and across the country.
What are the different uniform data sets and what type of health care organization will be using
that particular data set? - Answers UHDDS (Uniform Hospital Discharge Data Set)- Medicare and
Medicaid programs
ACDS (Uniform Ambulatory Care Data Set)- ambulatory and outpatient settings
, MDS (Minimum Data Set)- Long term care
What are the different types of comparative health care data sets and how might they be utilized?
- Answers Patient satisfaction- This is good for benchmarking and can help improve methods
so they can grow their business and keep consumers happy.
Practice Patterns- This can help improve practice patterns.
Health Plans- to help compare and pick the right one for you.
Clinical indicators- shows accreditation status and performance measures.
Population's measures- shows managers the demographics of the area.
What is the difference between data, information and knowledge and be able to distinguishes
the differences of each? - Answers Information is processed data.
Knowledge is defined as a combination of rules, relationships, ideas, and experiences.
Knowledge is the highest level in the hierarchy.
Poor quality data originates from two major areas. What are they? - Answers content and form
According to the Medical Record Institute, identify the 5 major functions negatively affected by
poor quality data. - Answers Patient Safety
Public Safety
Continuity of Patient Care
Health Care Economics
Clinical Research and Outcomes Analysis
What is the definition of information capture? - Answers is the process of recording
representations of human thought, perceptions, or actions in documenting patient care, as well
as device-generated information that is gathered and/or computed about a patient as part of
health care.
what is the definition of report generation? - Answers consists of the formatting and/or
structuring of captured information. It is the process of analyzing, organizing, and presenting
recorded patient information for authentication and inclusion in the patient's healthcare record.
What are the key principles developed by the MRI that should be adhered to in order to ensure
data quality? - Answers Unique patient identification must be assured within and across
healthcare documentation systems.
Healthcare documentation must be: accurate and consistent, complete, timely, interoperable
across types of documentation systems, accessible at any time and at any place where patient
