Domain 1 Practice Test

Question 1

The EHR may have multiple versions of the same document; for example, a signed and unsigned
copy. How can a healthcare organization manage version control of documents in the EHR?

Answer 1

The health record may have multiple versions of the same document; for example, a signed and an unsigned
copy of a document. To address the issues that result from having multiple versions of the same document,
policies and procedures addressing version control must be developed (Sayles 2020b, 81–82).

Question 2

The master patient index (MPI) manager has identified a pattern of duplicate health record
numbers from the specimen processing area of the hospital. The MPI manager merged the
patient information and corrected the duplicates in the patient information system. After this
merging process, which department should the MPI manager notify to correct the source system
data?

Answer 2

As the HIM department merges two duplicates together, the source system (laboratory) also must be corrected.
This creates new challenges for organizations because merge functionality could be different in each system or
module, which in turn creates data redundancy. When duplicates are identified, the department managers need to
be notified. Addressing ongoing errors within the MPI means an established quality measurement and
maintenance program is crucial to the future of healthcare (Sayles 2020b, 72).

Question 3

A health data analyst has been asked to compile a report of the percentage of patients who had
a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What
clinical reports in the health record would the health data analyst need to consult in order to
prepare this report?

Answer 3

Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test was
performed. Medication Administration Records (MAR) should be reviewed to determine if heparin was given after
the PTT test was performed (Brickner 2020a, 106, 108).

Question 4

Which of the following would be the best technique to ensure that registration clerks
consistently use the correct notation for assigning admission date in an EHR?

Answer 4

Templates are a cross between free text and structured data entry. The user is able to pick and choose data that
are entered frequently, thus requiring the entry of data that change from patient to patient. Templates can be
customized to meet the needs of the organization as data needs change by physician specialty, patient type
(surgical/medical/newborn), disease, and other classification of patients. In this situation a template would
provide structured data entry for the admission date (Sayles and Kavanaugh-Burke 2021, 217 ).

Question 5

Clinical documentation systems that support clinical decision-making capture data via which of
the following?

Answer 5

Structured data are required for a CDS system; hence, templates guide collection of the structured data. Digital
dictation and scanned images do not yield structured data for subsequent processing in a CDS system. Alerting
programs are one of (many) functions of a CDS system (Bowe and Williamson 2020, 368–369).

Question 6

Cancer registries are maintained by hospitals

Answer 6

Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by state law. Many
states require that hospitals report their data to a central statewide registry or incidence surveillance program
(Sharp 2020, 202).

Question 7

Dr. Smith wants to use a lot of free text in his EHR. What should be your response?

Answer 7

Because the ability to manipulate the data is reduced, it is recommended that little, if any, free text is used
(Sayles 2020b, 82).

Question 8

Copies of personal health records (PHRs) are considered part of the designated record set when

Answer 8

Organizational policy should address how personal health information provided by the patient will or will not be
incorporated into the patient’s health record. Copies of personal health records (PHRs), created, owned, and
managed by the patient, are considered part of the legal health record when the organization uses them to
provide treatment; however, the PHR does not replace the legal health record (Fahrenholz 2017c, 57).

Question 9

A medical group practice has contracted with an HIM professional to help define the practice’s
designated record set. Which of the following should the HIM professional perform first to
identify the components of the designated record set?

Answer 9

Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the
release of health records.
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The HIM professional should advise the medical group practice to develop a list of statutes, regulations, rules,
and guidelines regarding the release of the health record as the first step in determining the components of the
legal health records (Rinehart-Thompson 2017b, 170–171).

Question 10

The credentialing process of independent practitioners within a healthcare organization must be
defined in

Answer 10

The credentialing and privileging process for the initial appointment and reappointment of independent
practitioners should be defined in the healthcare organization’s medical staff bylaws and should be uniformly
applied (Shaw and Carter 2019, 279).

Question 11

Which of the following is the goal of the quantitative analysis performed by HIM professionals?

Answer 11

Reviewing for deficiencies is an example of quantitative analysis. The goal of quantitative analysis is to make sure
there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process
ensures a complete health record (Sayles 2020b, 76–77).

Question 12

In a routine health record quantitative analysis review, it was found that a physician dictated a
discharge summary on 1/26/20XX. Because of unexpected complications; however, the patient
was discharged two days after the discharge summary was dictated. What would be the best
course of action in this case?

Answer 12

If missing or incomplete information is identified during record analysis, HIM personnel can issue deficiency
notification(s) to the appropriate caregiver to assure the completeness of the health record. An addendum is a
supplement to a signed report that provides additional health information within the health record. In this type of
correction, a previous entry has been made and the addendum provides additional information to address a
specific situation or incident (Sayles 2020b, 78).

Question 13

Which of the following is not a recommended guideline for maintaining integrity in the health
record?

Answer 13

Data integrity is the assurance that the data entered into an electronic system or maintained on paper are only
accessed and amended by individuals with the authority to do so. Data integrity includes data governance, patient
identification, authorship validation, amendments and record correction, and audit validation for reimbursement
purposes. These functions ensure that the data is protected and altered by authorized individuals as per policy.
Assuring documentation that is being changed is permanently deleted from the record would not be a guideline
for maintaining the integrity of the health record (Brinda 2020, 172–173).

Question 14

To comply with the Joint Commission standards, the HIM director wants to ensure the history
and physical examinations are documented in the patient’s health record no later than 24 hours
after admission. Which of the following would be the best way to ensure the completeness of
the health record?

Answer 14

The quantitative analysis or record content review process can be handled in a number of ways. Some acute-care
facilities conduct record review on a continuing basis during a patient’s hospital stay. Using this method,
personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient’s recordThis type of process is usually referred to as a concurrent review because review occurs concurrently with the
patient’s stay in the hospital (Sayles 2020b, 76–77).

Question 15

Which of the following is true about the legal health record?

Answer 15

One of the major purposes of a health record is to serve as the legal business record of an organization and as
evidence in lawsuits or other legal actions, and as such, it would be the record released upon a valid request
(Rinehart-Thompson 2017b, 170–171).

Question 16

How is the patient registration department assisted by the HIM department?

Answer 16

The health record typically begins in patient registration with the capture of patient demographic information.
The health record is assigned to new patients during the patient registration process. The HIM department works
with patient registration to ensure the quality of the data collected and to correct duplicate and other issues with
the MPI (Sayles 2020b, 71–72).

Question 17

A new health information management (HIM) director has been asked by the hospital CIO to
ensure data content standards are identified, understood, implemented, and managed for the
hospital’s EHR system. Which of the following should be the HIM director’s first step in carrying
out this responsibility?

Answer 17

Data standards are the agreed-upon specifications for the values acceptable for specific data fields. Data
standards allow healthcare organizations to exchange health information in a format that ensures the data
remain comparable. A number of different types of data standards are used in healthcare to capture all of the
administrative and clinical data that is needed. Identifying data content requirements for all areas of the
organization would be the first step to ensure data content standards are identified, understood, implemented,
and managed for the hospital’s EHR system (Bowe and Williamson 2020, 383–384).

Question 18

Which of the following is a risk of copy and pasting documentation in the electronic health
record?

Answer 18

In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This
practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity
of using copy functionality includes propagation of false information in the record (Sayles 2020b, 82).

Question 19

Which of the following data sets would be most helpful in developing a hospital trauma data
registry?

Answer 19

Data Elements for Emergency Department Systems (DEEDS) is a data set to support the uniform collection of data
in hospital-based emergency departments and to reduce incompatibilities in emergency department records.
Because DEEDS is based on emergency department records it would be helpful in developing a trauma registry
(Brinda 2020, 156).

Question 20

The clinical forms committee is the entity within a healthcare facility that

Answer 20

Every healthcare facility should have a clinical forms committee to establish standards for design and to approve
new and revised forms. The committee should also have oversight of computer screens and other data capture
tools (Sayles 2020b, 79).

Question 21

Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in
the health record. She should educate the class against doing which of the following?

Answer 21

To correct errors or make changes in the paper health record, a single line should be drawn in ink through the
incorrect entry. The word error should be printed at the top of the entry along with a legal signature or initials,
date, time, and discipline of the person making the change (Sayles 2020b, 78).

Question 22

Which of the following specialized patient assessment tools must be used by Medicare-certified
home care providers?

Answer 22

Medicare-certified home healthcare uses a standardized patient assessment instrument called the Outcomes and
Assessment Information Set (OASIS). OASIS items are components of the comprehensive assessment that is the
foundation for the plan of care (Selman-Holman 2017, 345).

Question 23

Which of the following is part of qualitative analysis review?

Answer 23

Qualitative analysis is about the quality of the documentation including the use of approved abbreviations (Sayles
2020b, 76).

Question 24

The HIM manager was asked by the medical director to present the hospital’s policy on deletion
of erroneous information from the electronic health record (EHR) to the medical staff. This
policy requires that the original documentation is retained in the EHR along with the corrected
documentation. Which of the following is a key component of this policy?

Answer 24

Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event that
an amendment, addendum, or deletion needs to be made the EHR should retain the previous version of the
document and identify who made the change along with the date and time that the change was made (Sayles
2020b, 81–82).

Question 25

Before healthcare organizations can provide services, they usually must obtain this from
government entities such as the state or county in which they are located.

Answer 25

Licensure is the state’s act of granting a healthcare organization or individual practitioner the right to provide
healthcare services of a defined scope in a limited geographic area. It is illegal in all 50 states to operate
healthcare facilities and practice medicine without a license (Fahrenholz 2017a, 82).

Question 26

The following descriptors about the data element ADMISSION_DATE are included in a data
dictionary—definition: date patient admitted to the hospital; data type: date; field length: 15;
required field: yes; default value: none; template: none. For this data element, data integrity
would be better assured if

Answer 26

A pattern used in electronic health records to capture data in a structured manner is called a template. One
benefit of using a template is to ensure data integrity upon data entry (Brickner 2020a, 95).

Question 27

Managing an organization’s data and those who enter it is an ongoing challenge requiring active
administration and oversight. This can be accomplished by the organization through
management of which of the following?

Answer 27

A data dictionary is a descriptive list of the data elements to be collected in an information system or database
whose purpose is to ensure consistency of terminology (Brinda 2020, 155–156).