1 | Page
Chapter 23: The Medical Record,
Documentation, and Filing Questions and
Answers 2026 Latest Update
What is one of the most widely used methods of charting,
appropriate for most types of patient encounters?
a. POMR note
b. HPIP note
c. SOAP note
d. CHEDDAR note Ans: c. SOAP note
What type of progress note is organized and entered based on
where medical documentation came from, whether from a
provider, laboratory, or other source?
a. POMR note
b. CHEDDAR note
c. HPIP note
d. SOAP note Ans: a. POMR note
What area of HIPAA pertains primarily to records management?
© 2025 All rights reserved
, 2 | Page
a. Establishing standards for any electronic transmission of
physician information
b. Maintaining the privacy of physician information
c. Overseeing the use of electronic appointment scheduling
d. Ensuring the security of all electronic health information Ans: d.
Ensuring the security of all electronic health information
In the event of an audit, the Centers for Medicare & Medicaid
Services (CMS) will ask for documentation to evaluate how that
office is complying with the security standards of the Security
Rule. Which of the following is part of that evaluation?
a. Clinical safeguards
b. Physician safeguards
c. Oversight safeguards
d. Administrative safeguards Ans: d. Administrative safeguards
Having policies and procedures in place that identify and protect
reasonably anticipated threats to the security or integrity of the
information and to protect against reasonably anticipated,
impermissible uses or disclosures, applies to compliance within
which HIPAA rule?
a. Security Rule
b. Safety Rule
© 2025 All rights reserved
Chapter 23: The Medical Record,
Documentation, and Filing Questions and
Answers 2026 Latest Update
What is one of the most widely used methods of charting,
appropriate for most types of patient encounters?
a. POMR note
b. HPIP note
c. SOAP note
d. CHEDDAR note Ans: c. SOAP note
What type of progress note is organized and entered based on
where medical documentation came from, whether from a
provider, laboratory, or other source?
a. POMR note
b. CHEDDAR note
c. HPIP note
d. SOAP note Ans: a. POMR note
What area of HIPAA pertains primarily to records management?
© 2025 All rights reserved
, 2 | Page
a. Establishing standards for any electronic transmission of
physician information
b. Maintaining the privacy of physician information
c. Overseeing the use of electronic appointment scheduling
d. Ensuring the security of all electronic health information Ans: d.
Ensuring the security of all electronic health information
In the event of an audit, the Centers for Medicare & Medicaid
Services (CMS) will ask for documentation to evaluate how that
office is complying with the security standards of the Security
Rule. Which of the following is part of that evaluation?
a. Clinical safeguards
b. Physician safeguards
c. Oversight safeguards
d. Administrative safeguards Ans: d. Administrative safeguards
Having policies and procedures in place that identify and protect
reasonably anticipated threats to the security or integrity of the
information and to protect against reasonably anticipated,
impermissible uses or disclosures, applies to compliance within
which HIPAA rule?
a. Security Rule
b. Safety Rule
© 2025 All rights reserved
