Final Exam Review WorksheetQuestions and Concepts
1. What is the national association for
HIM professionals?
2. What is the role of the HIM
professional within the healthcare
organization?
3. What are the two credentials
available to HIM professionals?
4. What is the purpose of the patient’s
health record?
5. Who uses the patient’s health
record?
6. Is the health record a primary or
secondary source of information?
7. Can you provide examples of
secondary sources of information?
8. What are the three formats for the
paper-based health record?
Describe these 3 formats.
9. What determines the patient’s level
of care?
10. What is the role of the Medical Staff
Committee?
11. What is the role of the hospitalist
within healthcare?
12. Can you name some regulatory and
accrediting agencies that govern
the healthcare record?
13. What is the role of Risk
Management?
14. What is a critical care access
hospital?
15. How does a specialty hospital differ
from a rehabilitation hospital?
16. What is an Adult Daycare Center?
17. What services do a skilled nursing
facility provide?
18. What is palliative care?
19. What are the two types of data
contained within the patient’s
health record?
20. Identify two external agencies that
govern the patient’s health record?
21. What is the purpose of the
Discharge Summary?
22. What are the timeliness
requirements of the Discharge
Summary?
23. What is the purpose of the History
and Physical?
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Final Exam Review Worksheet
Questions and Concepts
24. What are the timeliness
requirements of the History and
Physical?
25. What is the purpose of the
physician’s order?
26. What is the frequency required of
progress notes?
27. What is a pathology report? When is
it required?
28. What is an autopsy report? Who
signs the consent for an autopsy
report?
29. What is informed consent?
30. Who performs a consultation
report?
31. When is a transfer summary
required?
32. What are data sets? What are their
purpose?
33. What healthcare setting uses
OASIS?
34. What healthcare setting uses
DEEDS?
35. What healthcare setting uses MDS?
36. What healthcare setting uses
UHDDS?
37. What are the basic documentation
principles?
38. Who governs documentation?
39. What is CDI? What is its goal?
40. When do CDI reviews usually begin
and end?
41. What is a hybrid record?
42. In what record format will you find
SOAP notes?
43. What are the goals of the electronic
health record?
44. Do some medical organizations still
use the paper-based record?
45. What is the role of the HIM
professional in regards to the
patient healthcare record?
46. What is CPOE?
47. What is HIE?
48. What is meaningful use?
49. What is SNOMED? What is its
purpose within the electronic health
record?
Page 2 of 4
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comments that help you understand the element
or concept
Final Exam Review Worksheet
Questions and Concepts
50. What does interoperability mean in
regards to the electronic health
record?
51. What is a PHR?
52. How does the PHR differ from the
EHR?
53. Who controls access to the PHR?
54. Can you name some functions
performed within a HIM
department?
55. What is the MPI? What is its
purpose?
56. How does the MPI affect the
functions within a HIM department?
57. How does a duplicate record result?
58. What is the unit numbering?
59. How can paper-based patient health
records be filed?
60. What are the advantages of
terminal digit filing?
61. How are errors in a paper-based
record corrected?
62. How are errors in an electronic
health record corrected?
63. What is an addendum in regards to
the health record?
64. What is an amendment in regards
to the health record?
65. What is the purpose of the
Forms/Design Committee?
66. Why do forms that go into the
health record need to be regulated?
67. What is aggregate data?
68. What are the four purposes for
collecting secondary data?
69. Who uses secondary data?
70. What is an index? What three
indexes are used in healthcare?
71. What is a registry? Review the
various registries
72. What is data stewardship?
73. What is privacy?
74. What is confidentiality?
75. What is security?
76. What is the purpose of a security
program?
Page 3 of 4
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located this information in your textbook,
comments that help you understand the element
or concept
Final Exam Review Worksheet
Questions and Concepts
77. Identify access security
mechanisms used to verify the
user.
78. What is data granularity?
79. What is data consistency?
80. What is data accuracy?
81. What is data integrity?
82. What is a breach?
83. What is the procedure if a breach of
patient information occurs?
84. What is the purpose of HL7?
85. Why do we need standards in terms
of data transmission?
86. What is coding?
87. Explain the coding process.
88. What is ICD-10-CM? How is it used?
89. What is ICD-10-PCS? How is it
used?
90. What is CPT? How is it used?
91. What is ICD-O-3? How is it used?
92. What is HCPCS? How is it used?
93. What is DSM? How is it used?
94. What is an encoder?
95. What is CAC?
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