HIM QUESTIONS 2024/25 QUESTIONS BANK
WITH CORRECTLY ANSWERED SOLUTIONS!!
What is not a core competency of HIM Professionals (Biomedical science, technology, management, access and privacy, health information analysis) Answer - Technology Are non HIM members part of CHIMA board? Answer - Yes
CCHIM is responsible for (select all that apply: A. establishes the learning
outcomes for HIM programs, B identifies the standards of practice for entry level HIMs C. Creates and manages the national certification exam) Answer - A, B and C
T or F: All entries in a health record whether paper or electronic need to be
authenticated? Answer - True A newborn's record is filed with its mothers? Answer - No
T or F: Abbreviations are never allowed in a health record Answer - False
T or F: Specificity means that data needs to meet needs for clinical care only
Answer - False
T or F: Prior to elective surgery a patient will sign a Consent for Release of
Information Answer - False 1 / 4
What are some typical elements of qualitative record analysis Answer - Diagnosis inconsistencies, inconsistencies in identification (name of patient, DOB), time or location gaps, use of non approved abbreviations What occurs after qualitative and quantitative record analysis is complete?Answer - Coding and abstracting What is the primary purpose of a health record? Answer - To support the continuity of care Secondary uses of the health record? Answer - Facilitate clinical decision making, funding, education, research, operational management, legislation, support quality of care
Qualitative analysis is an important tool to ensure data quality. It evaluates:
potential risk events, adverse drug reactions, quality of documentation, quality of care through use of established criteria. Answer - Quality of documentation
T or F: While doing a final check on a paper record an HIM notices a lab report
is missing, once printed and added to the record, it can then be filed. Answer - False- further analysis may be needed as well as coding and abstracting
Discharge summary documentation must include: A. Detailed history of
patient, B discharge order, C. significant findings during hospitalization. D. A and C, E. All of the above Answer - C. Significant findings during hospitalization
T or F: Redacting an entry in a record means deleting an error. Answer - False
T or F: If a patient presents their provincial health card at registration, there is no need to search the MPI Answer - False 2 / 4
Where would you expect to find this entry in a record: The patient was
admitted to the medical unit. He was started on Levaquin 500mg and then later reduced to 250mg daily. The patient was hydrated with IV fluids. Cardiac enzymes were done 2 days. The chest pain resolved; ECG was unchanged.Patient will be followed as an outpatient. Answer - Discharge summary
T or F: The chart order in a paper record is determined by a Health Record
Committee Answer - True
T or F: A delinquent record is the same as a deficient record. Answer - False
What is the key principle of the ADT? Answer - Collect once, use many
T or F: Verifying that a key document of a record is included and authenticated
is a key step in qualitative analysis? Answer - False. Quantitative analysis T or F: The unintentional mis-identification of an individual is identity theft?Answer - False Someone registers at a desk and the clerk finds 2 entries in the MPI this is an
example of a: Answer - Duplicate
Accurate client identification requires: A Clearly defined data elements B.
Organizational policies and procedures that are audited and enforced C.Rigorous staff training D. Standards for data recording E. All of the above Answer - E. All of the above. 3 / 4
Advantages of concurrent coding include. A. Identifications of conditions that might have been overlooked. B. More timely coding C. Faster qualitative and quantitative analysis. D. All of the above Answer - D. All of the above.What is the framework that facilitates communication between providers?Answer - Nomenclature and terminologies Who manages SNOMED-CT Answer - IHTSDO (International Health Terminology Standards Development Organization) Who manages ICD in Canada? Answer - CIHI
T or F: DSM-IV and CCI share codes Answer - False
T or F: DSM-IV and ICD share codes Answer - True
What is the terminology of the EHR? Answer - SNOMED-CT Coding is based on whose documentation? Answer - Physician's Does the coder assign CMG or level of complexity? Answer - No How many levels of complexity can there be in each CMG Answer - 4 Case Mix Groups (CMG) are used for what type of data? Answer - Inpatient What are Major Clinical Categories related to? Answer - Case mix groups- each major diagnosis has a major clinical category and then within that are the cmg
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