Intro to Health Information Management Technology (HIMT) Practice Exam

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• Patients who undergo procedures that can be performed on an outpatient basis are categorized as which type?
• Admission data entry system used to create admission log and daily census.
• Which describes the primary purpose of an audit trail in an HIS?
• What is multi-factor authentication and why is it used?
• What constitutes a breach under HIPAA?
• What is the difference between data validation and data verification?
• What does "coding to the highest level of specificity" mean?
• How does data governance differ from data management?
• Why is a retention schedule important in records management?
• Which factors are considered in classifying a DRG for reimbursement?
• Who is responsible for HIPAA privacy compliance, risk assessments, training, and breach response in an organization?
• Which term describes the practice of removing identifiers from data to protect patient privacy?
• Which organization works with The Joint Commission to standardize the National Hospital Quality Measures?
• Which statement best distinguishes anonymization from pseudonymization?
• What coding system is used to report procedures for inpatient hospital services for payment with DRGs?
• Which item qualifies as PHI?
• In serial-unit numbering, if a patient is renumbered and the old folder remains with a note indicating the new number, what is demonstrated?
• Which statement about data governance tools is most accurate?
• Which component is responsible for determining medical necessity before claims submission in the inpatient revenue cycle?
• Which of the following is NOT one of the six common data quality dimensions in HIM?
• Which of the following is NOT typically considered administrative data?
• Ms. HIM files the following records: 223345, 223346, 223347, 223348, and 223349. Which filing system is being used?
• The CSP certification is offered by which organization?
• What does interoperability mean in the context of HIM?
• What is one of the primary responsibilities of a Security Officer in HIM?
• In terminal-digit filing, what is the color pattern for record number 39-09-15?
• What is the key difference between ICD-10-CM and ICD-10-PCS coding?
• Which statement about a data dictionary is accurate?
• In telehealth documentation, which element is essential to record for reimbursement and compliance?
• What does NPO stand for?
• Which list is used to locate a patient's health care encounters across different departments within a facility?
• Utilization Manager is described as equivalent to which other role?
• Which color corresponds to the digit 0?
• Suzie Smith wants to obtain a copy of her medical record. She can obtain a copy of all reports in her record EXCEPT for the
• Which statement describes an essential goal of health information management in hospitals?
• How do a data dictionary and a data glossary differ?
• Which statement about a data element is correct?
• How many characters are in a typical ICD-10-PCS code?
• Which statement best describes the UHDDS?
• What is a data dictionary?
• What is the role of chart abstraction guidelines in HIM?
• Which of the following best defines Protected Health Information (PHI)?
• What is the typical HIPAA breach notification timeline?
• What does the HIPAA/HITECH Act emphasize regarding privacy and security?
• Distinguish between active and inactive records.
• Which statement about the relationship between LHR and PHI is true?
• Which of the following is NOT a main stage of the health information lifecycle?
• Which organization collects and exchanges information about insured individuals' medical histories for underwriting?
• Patients treated and released the same day and do not stay overnight in the hospital are considered what type of patients?
• PHI stands for
• Administrative data includes which of the following types of information?
• Which statement correctly describes HIPAA regulation?
• What is a PACS and what does it manage?
• In an emergency department, what is the quickest way to determine whether a patient has been previously seen at the facility?
• The history and physical examination must be documented within how many hours of inpatient admission?
• In HIPAA de-identification, what does the Expert Determination method require?
• What are the key privacy protections required by HIPAA for PHI?
• Which statement correctly defines ePHI?
• What is an HIE?
• What does data portability mean in the context of HIM data exchange?
• What is chart abstraction?
• How do SNOMED CT and ICD-10-CM interoperate?
• What is the primary goal of clinical documentation improvement (CDI)?
• Which statement best defines administrative data?
• Which statement best describes the purpose of the DICOM standard?
• Which option describes a primary function of a data dictionary?
• Arrange the following numbers in middle-digit order: 01-30-49, 01-31-40, 02-30-49, 02-36-40, 20-39-50, 03-40-50.
• Which four core data quality dimensions are used in HIM?
• What is the role of a Privacy Officer?
• Which coding systems are used for diagnoses and procedures in most US health care settings?
• A common item not found on an admission data entry screen is:
• Tom Jones is admitted to Sunny View Hospital and assigned patient number 123456. One year later he is readmitted and assigned 133890. The original record is renumbered to 133890 and filed in the new folder also numbered 133890. The system being used is called:
• What is a health information exchange (HIE)?
• Which statement about the role of a CDI specialist is true?
• Which data quality dimension ensures data is consistent across datasets?
• Suzy Staff's job title is utilization manager, which means the same as which role?
• Which job title is described as coordinating preparation for surveys and monitoring facility compliance with accreditation standards?
• Which of the following is one of the five core functions of the NIST Cybersecurity Framework?
• HIPAA, expanded acronym, stands for:
• What is the role of a data steward in governance?
• Which data type is used to document medical conditions, diagnoses, and treatment plans?
• Patient identification information collected according to facility policy (name, date of birth, place of birth, mother's maiden name) is called what kind of data?
• HCPCS Level II codes primarily cover?
• What is a typical retention period for adult inpatient medical records?
• In healthcare, what is a quality measure?
• What is data provenance in Health Information Management?
• What is another term for the additional authentication used after the author's signature?
• HIPAA breach notifications generally must be provided within how many days of discovery?
• What is a KPI in health information management?
• In terminal digit filing, which digits determine the order?
• How is death certificate data used in health statistics?
• In ICD-10-CM coding, what does 'code first' indicate?
• LOINC is used for what purpose in health data?
• Which data element is typically part of demographic data?
• What tool is used to translate clinical concepts between SNOMED CT and ICD-10-CM?
• Excludes notes in ICD-10-CM/PCS coding guidelines are used to indicate what?
• The admission diagnosis entered on the patient record is an example of which data type?
• What is de-identification under HIPAA?
• Under HIPAA, authorization to disclose PHI is not required in which scenario?
• Which two organizations collaborate to standardize National Hospital Quality Measures?
• What is the role of a data owner versus a data steward in governance?
• What workflow steps are typically involved in ROI?
• What is HL7 and why is it essential in HIM?
• What is the primary function of the Health Information Management (HIM) department?
• What is the role of a CDI specialist?
• What is descriptive analytics in healthcare data?
• What is the purpose of a data dictionary in an HIS?
• Which standard is primarily used for clinical terminology and vocabularies in HIM?
• Ms. HIT files the following records: 13-40-05, 14-40-05, 14-41-05, 15-41-05, and 16-41-05. Which filing system is being used?
• Which database would a hospital use to verify a practitioner's licensure status and any disciplinary actions on a national level?
• Differentiate between abstracting data and CDI queries.
• In the context of EHRs, what does longitudinal mean?
• Which organization established in the 1970s provides an external peer review process for correctional health services to meet national standards?
• Which of the following is true about ICD-10-PCS?
• Which description best defines data governance?
• Define ePHI.
• In a breach affecting more than 500 individuals, which additional notification must be made to the public?
• In the nursing home advertisement, the job title described would be which?
• In data governance, who is responsible for day-to-day data handling and quality management?
• Which organization is most closely associated with reporting medical malpractice payments and adverse actions about health care practitioners?
• The admission date and discharge date are considered:
• The Joint Commission requires patient records to be completed within _____ days after discharge.
• CDI programs are designed to improve what three areas?
• A form of authentication by an individual in addition to the signature by the original author is known as:
• In HIM organizations, which roles are commonly included in data governance committees?
• Under HIPAA, what rights do patients have regarding access to their medical records?
• What is the role of HL7 in health IT interoperability?
• Differentiate the HIPAA Privacy Rule from the HIPAA Security Rule.
• Which statement about the Legal Health Record (LHR) is true?
• What is data stewardship?
• What is the primary purpose of the AHIMA Code of Ethics in Health Information Management?
• What is a Diagnosis-Related Group (DRG)?
• Which description best captures descriptive analytics in healthcare?
• Which source is most appropriate for verifying a physician's licensure history and any malpractice actions during privilege applications?
• Which statement correctly differentiates a dataset from a data element?
• What penalties may result from HIPAA violations?
• A group medical practice typically consists of how many physicians?
• AHIMA requires RHITs and RHIAs to submit proof of continuing education every two years.
• Which data quality dimension focuses on the ability to retrieve data for use when needed?
• What is the primary role of a data steward in an organization?
• Which form of PHI does the HIPAA Security Rule specifically require safeguards for?
• The role responsible for safeguarding patient health information policies is called the ...
• Which statement defines the Master Patient Index?
• What is FHIR and why is it important?
• SNOMED CT is used for which purpose in health information management?
• Movable files are also known as:
• What is the Legal Health Record (LHR)?
• How does HIM support telehealth documentation and reimbursement?
• Which is an example of clinical data?
• Which of the following is a stage in the health information lifecycle?
• What does role-based access control (RBAC) mean in health IT?
• What is the primary purpose of a clinical documentation improvement (CDI) program's query process?
• Name the three primary categories of PHI disclosures without patient authorization.
• Which of the following is NOT a common health information standard used in HIM?
• Which statement accurately describes the data definitions in a data dictionary?
• Chart abstraction is used to extract structured data from medical records for coding, quality reporting, or research.
• A written command or direction ordered by a court or judge?
• Which department is typically responsible for verifying licensure and malpractice history when granting hospital privileges?
• Which step is typically performed in ROI to verify the requester’s identity?
• The difference between Legal Health Record (LHR) and Personal Health Record (PHR) is that:
• What do Official Coding Guidelines advise about principal diagnosis assignment?
• Which term describes the mechanism that identifies a single patient across multiple encounters within the same facility?
• What is the DEEDS data set?
• The UHDDS standardizes inpatient data elements for national and regional statistics and reporting.
• What is the ROI process?
• A hospital that provides emergency care, performs surgery, and admits patients for a range of problems is a ____ hospital?
• What is an access control in health information security?
• Which problem in health records is most likely reduced by maintaining an accurate Master Patient Index?
• Define protected health information (PHI).
• Which filing system uses the middle digits to order records?
• Which Act provides open access to federal agency records?
• Which color is mapped to the digit 9?
• What is a clinical data repository?
• A court order that requires an individual to appear in court to testify is called what?
• What is CPT coding used for, and what is HCPCS Level II coding used for?
• A case manager coordinates patient care to ensure timely discharge or transfer.
• Which statement best describes a data glossary?
• Which statement about HIEs is most accurate?
• Which hospital service is most commonly provided in an ambulatory care setting rather than inpatient wards?
• Which of the following is an example of HIPAA Safe Harbor de-identification?
• Which statement about KPI in HIM is true?
• The director of health information has received a written document requiring her to appear in court and bring any and all records on patient Polly Jones. The document she received is called a
• Which set comprises core components of the inpatient revenue cycle?
• Who transcribes prerecorded dictation to create medical records, correspondence, and other administrative material?
• Which statement best describes HIPAA/HITECH breach notification requirements?
• Which standard is used for coding diagnoses and inpatient procedures for billing?
• Which statement best differentiates an Electronic Health Record (EHR) from a traditional paper record?
• Which statement about the HIPAA privacy rule is true?
• Which data quality dimension ensures information accurately reflects the real-world events it represents?
• Process to determine distribution of patients by diagnosis and procedure to assess resource needs
• Which governance body oversees data quality, privacy, and access within an HIM organization?
• What is an amendment request in the context of patient rights?
• The agency within the U.S. Department of Health and Human Services that focuses on aging services to enable seniors to remain independent is called the
• AHIMA stands for which organization?
• Tom was injured on the job. According to HIPAA, which would have the right to access his protected health information regarding that job injury?
• Inpatients admitted to critical access hospitals are restricted to stays of how many hours?
• Which organization is the premier medical research organization in the United States that supports research projects nationwide?
• Which of the following is the full name of the agency commonly abbreviated as AoA?
• Which statement about the Master Patient Index is true?
• Which statement best describes SNOMED CT used for?
• Which statement best defines Protected Health Information (PHI) under HIPAA?
• Which organization is commonly associated with hospital accreditation in the United States?
• Which term describes the disciplined management and accountability for data assets, including quality, privacy, and access?
• Which of the following tasks is typically performed by a medical transcriptionist?
• Which organization has offered and maintained accreditation programs for health care organizations since 1951?
• Who performs routine administrative and clinical tasks to keep the offices and clinics of physicians, podiatrists, chiropractors, and optometrists running smoothly?
• What does the 'minimum necessary' standard require in PHI disclosures?
• Which activity best describes the role of the HIM department in safeguarding patient information?
• Which national database serves as a repository for information on adverse actions related to health care practitioners?
• In the health information lifecycle, which stage involves sharing PHI with authorized entities?
• Under HIPAA breach notification requirements, by when must affected individuals be notified after discovery of a potential breach?
• Hospice care provides comprehensive medical and supportive social, emotional, and spiritual care to terminally ill patients and their families. The goal of hospice is to provide
• What are Safe Harbor identifiers under HIPAA de-identification?
• What is data governance in HIM?
• Which data quality dimension ensures data are present and not missing?
• Why is the 'minimum necessary' standard important in HIPAA disclosures?
• Time limit to respond to amendment requests under HIPAA.
• In the NIST CSF, which function focuses on restoring operations after a cybersecurity incident?
• De-identified health information under HIPAA
• What is the purpose of Official Coding Guidelines?
• Under HIPAA, when is breach notification required?
• What does ADT stand for?
• AHIMA's continuing education requirement explicitly names which groups?
• Which item is a focus of a HIPAA risk assessment?
• What best describes a risk assessment under the HIPAA Security Rule?
• Which term describes a record of system activity and user access to data used for security, accountability, and monitoring?
• Which agency within the U.S. Department of Health and Human Services focuses on aging services to help seniors stay independent?
• How does HIPAA permit reports to public health authorities?
• Which standard is designed to encode diseases, findings, procedures, and other clinical concepts?
• HIM department function called case mix analysis.
• Which term describes data elements used to identify a patient, including name and date of birth?
• Which term describes a formal recording of items, names, or actions?
• What does National Hospital Quality Measures refer to?
• What triggers HIPAA breach notification requirements?
• What is a diagnosis-related group (DRG) and how does it impact reimbursement?
• LOINC standardizes which of the following aspects of health data?
• Who is responsible for gathering information and recommending settlements concerning professionals and general liability incidents, claims, and lawsuits?
• What does DICOM stand for and why is it used?
• What is the difference between data quality and data governance?
• Exchange of data among multiple software products is known as: