Which of the following requires that the criteria of message integrity, nonrepudiation, and user authentication be used?

1. Your hospital is transitioning from paper-based records to electronic health records. Right now, part of

The record is paper, and some of it has been transitioned to electronic formats. AHIMA refers to this as a(n)

_______ Health record.

1. source-oriented
2. integrated
3. problem-oriented
4. hybrid
5. Which of the following is required by the Joint Commission for ambulatory charts?
6. Discharge summary
7. Medication list
8. Consent to treat
9. Problem list
10. You’re reviewing patient information in which resolution is a big factor. What system are you most likely

to be using?

1. Pharmacy
2. Biomedical
3. Radiology
4. Dictation/transcription
5. Which of the following is an example of a secondary record?
6. Demographic data
7. Lab results
8. SOAP note
9. Billing claim
10. In reverse chronological order, the _______ patient record is the most common record used.
11. problem-oriented
12. integrated
13. hybrid
14. source-oriented
15. Admission and discharge notes are examples of
16. demographic data.
17. primary records.
18. secondary records.
19. claims.
20. Which of the following is required by CMS?
21. DEEDS
22. UCDS
23. OASIS
24. NCDB
25. You sit on the electronic health record committee that has decided to get systems that work best for each

department. This method is known as the _______ approach.

1. best-of-breed
2. integrated systems
3. LOINC
4. hanging protocol
5. Which of the following requires that the criteria of message integrity, nonrepudiation, and user

authentication be used?

1. Flow sheets
2. Nomenclature
3. EHR forms
4. Electronic signatures
5. Which of the following is an example of a secondary record?
6. Dental record
7. Ambulatory care record
8. MPI
9. Physician order
10. Which of the following is required by the CMS?
11. Refusal of treatment
12. Advanced directive
13. Medicare patient rights statement
14. HIPAA consent
15. Which of the following is used for planning care in an SNF?
16. Data sets
17. SOAP
18. Case management
19. RAI
20. The nurse indicates that the patient in Room 302 is DNR. Where would you look to confirm this?
21. Patient rights statement
22. Advance directives
23. Disclosure records
24. Assignment of benefits
25. The admission clerk misspells a patient’s name and therefore can’t find him in the system, so a new

number gets assigned and a chart created. This problem is a common downfall of

1. electronic records.
2. common names.
3. paper records.
4. unit numbering.
5. Which of the following is considered a public health record?
6. Medical history
7. Organ donor
8. Referral consult
9. Death record
10. Which of the following does AHIMA recommend keeping permanently?
11. Death registry
12. Mammography
13. Children’s records
14. Pathology reports
15. You’re filing a patient’s paper record with the number 462-99-00. Your department is probably using

which filing system?

1. Alphanumeric
2. Straight numeric
3. Family numbering
4. Serial-unit
5. Which of the following is often used to meet Joint Commission compliance?
6. Unit numbering
7. Serial-unit numbering
8. Serial numbering
9. Family numbering
10. The downfall of this numbering system is that there may be multiple records for one patient.
11. Family numbering
12. Unit numbering

End of exam

1. Serial-unit numbering
2. Serial numbering
3. You’re looking at a patient’s paper record in which all the physician notes are grouped together in one

section, the lab results are grouped together in another section, and the nursing notes are organized in yet

another section. Which type of record are you most likely viewing?

1. Hybrid
2. Integrated
3. Source-oriented
4. Problem-oriented