Free SCFHS Health Informatics mock test

Health Informatics sample questions with answers

10 more original exam-style Health Informatics questions, worked in full. They are not real or recalled exam questions, and none of them is in the mock above or on the bank page, so sit the mock first if you have not.

1. Question 1 · Databases, Applications and Electronic Health Records

   What is the main difference between an electronic medical record (EMR) and an electronic health record (EHR)?

   1. AAn EMR is stored on paper files and an EHR is stored in digital form
   2. BAn EHR contains billing and insurance data and no clinical information
   3. CAn EMR is owned by the patient who controls access to it, while an EHR is owned by the hospital that runs it
   4. DAn EHR is designed to be shared across organisations, while an EMR is used within one
   Show answer and explanation

   Correct answer: D. An EHR is designed to be shared across organisations, while an EMR is used within one

   An EMR is the digital chart within a single practice or hospital, whereas an EHR can be shared across different providers. Both are digital, both hold clinical data, and ownership is not the distinguishing feature.

   Reference: Sayles (ed.), Health Information Management Technology: An Applied Approach, 5th ed. (AHIMA, 2016)

2. Question 2 · Ethical Issues in Health Information

   A patient disagrees with a diagnosis recorded in the chart and asks that it be deleted. What is the correct action under health information ethics?

   1. AKeep the original entry and add the patient's statement or a correction as an amendment
   2. BDelete the diagnosis from the chart
   3. CReplace it with the patient's preferred diagnosis
   4. DIgnore the request
   Show answer and explanation

   Correct answer: A. Keep the original entry and add the patient's statement or a correction as an amendment

   The record must stay intact and traceable, so corrections are made as dated amendments and the patient's view can be attached. Deleting or ignoring the request harms integrity or the patient's rights.

   Reference: AHIMA, Code of Ethics (2019)

3. Question 3 · Health Services and Health Insurance Management

   An insurer denies a claim because the diagnosis does not support the procedure billed. What should the health information department do?

   1. AReview the documentation and coding, and appeal with accurate supporting evidence
   2. BChange the diagnosis so that the claim is paid
   3. CBill the patient without review
   4. DDelete the procedure from the record
   Show answer and explanation

   Correct answer: A. Review the documentation and coding, and appeal with accurate supporting evidence

   The department must check whether the coding or documentation is wrong and appeal truthfully. Altering the record to obtain payment is fraud.

   Reference: Abdelhak & Hanken, Health Information: Management of a Strategic Resource, 5th ed. (2016)

4. Question 4 · Health Record Content, Structure and Format

   Which document must be completed and signed before a non-emergency surgical procedure?

   1. AInformed consent form
   2. BDischarge summary
   3. CDeath certificate
   4. DBirth certificate
   Show answer and explanation

   Correct answer: A. Informed consent form

   Informed consent must be obtained and documented before elective surgery. A discharge summary is written after the stay.

   Reference: Sayles (ed.), Health Information Management Technology: An Applied Approach, 5th ed. (AHIMA, 2016)

5. Question 5 · Databases, Applications and Electronic Health Records

   A hospital wants the marital status field to be entered in the same way by the registration clerks. Which design is best?

   1. AA free-text field with a spelling check
   2. BA drop-down list of allowed values with validation
   3. CA field left open and cleaned each month
   4. DA note field completed after discharge
   Show answer and explanation

   Correct answer: B. A drop-down list of allowed values with validation

   A controlled list stops variation at the point of entry. Free text, monthly cleaning and late completion all allow inconsistent entries that are costly to correct.

   Reference: Oachs and Watters (eds.), Health Information Management: Concepts, Principles, and Practice, 6th ed., 2020

6. Question 6 · Health Record Content, Structure and Format

   A physician remembers an important detail two days after the patient was discharged and wants to add it to the record. What is the correct way?

   1. AAdd a dated, timed late entry marked as late, leaving the original untouched
   2. BWrite over the original note with the new detail
   3. CBack-date the new entry to the day of care
   4. DAsk the file clerk to insert the detail into the original note quietly, unmarked
   Show answer and explanation

   Correct answer: A. Add a dated, timed late entry marked as late, leaving the original untouched

   A late entry keeps the original intact and shows when the addition was made. Overwriting, back-dating and clerk changes hide the true sequence and weaken the legal value of the record.

   Reference: Abdelhak et al., Health Information: Management of a Strategic Resource, 5th ed., 2015

7. Question 7 · Quality, Risk Management and Performance Improvement

   A fax with a patient's results is sent to the wrong number. After the recipient confirms destruction, what else must the department do?

   1. ANothing further, because the recipient destroyed it
   2. BReport it as a privacy incident for review and follow the breach policy
   3. CTell the patient's family and take no further action
   4. DDelete the fax log to avoid confusion
   Show answer and explanation

   Correct answer: B. Report it as a privacy incident for review and follow the breach policy

   Even a contained disclosure is an incident that must be reported so the cause can be fixed and the policy on notification applied. Doing nothing, telling relatives and deleting logs hide the event.

   Reference: Oachs and Watters (eds.), Health Information Management: Concepts, Principles, and Practice, 6th ed., 2020

8. Question 8 · Health Record Life Cycle and Functions

   Which feature best supports the use of a health record as reliable legal evidence?

   1. AEntries made at the time of care that are signed, dated and not altered afterward
   2. BEntries written from memory at the end of the month by whichever staff member is free
   3. CUnsigned notes completed by a colleague
   4. DHandwriting too personal for others to read
   Show answer and explanation

   Correct answer: A. Entries made at the time of care that are signed, dated and not altered afterward

   Courts rely on records made at or near the time of care by an identified author and kept unaltered. Late entries from memory, unsigned notes and unreadable writing weaken reliability.

   Reference: Abdelhak et al., Health Information: Management of a Strategic Resource, 5th ed., 2015

9. Question 9 · Ethical Issues in Health Information

   An insurer asks for the full record of a patient to process a claim for a minor procedure. Which principle should guide the response?

   1. ARelease the full record, because the insurer is paying
   2. BRefuse release even when the patient authorises it
   3. CRelease the minimum information needed for the claim, with the patient's authorisation
   4. DLet the insurer's clerk choose which pages to copy
   Show answer and explanation

   Correct answer: C. Release the minimum information needed for the claim, with the patient's authorisation

   Disclosure should be limited to the minimum necessary for the stated purpose and based on authorisation. Releasing everything exceeds the need, refusing blocks a valid purpose, and outsiders should not select pages themselves.

   Reference: AHIMA, Code of Ethics, 2019

10. Question 10 · Clinical Classification System

    A patient has a documented diagnosis of acute appendicitis, with abdominal pain and nausea that are integral to it. How should the coder treat the pain and nausea?

    1. ACode them both as extra diagnoses to raise the severity
    2. BCode them first and the appendicitis last, as the symptoms came first in time
    3. CNot code them separately, since they are routinely part of the diagnosis
    4. DCode the nausea, because it is the last symptom documented
    Show answer and explanation

    Correct answer: C. Not code them separately, since they are routinely part of the diagnosis

    Signs and symptoms that are integral to a confirmed diagnosis are not coded in addition to it. Adding them inflates the record, and the sequencing and the selection of one symptom have no support in the rules.

    Reference: Oachs and Watters (eds.), Health Information Management: Concepts, Principles, and Practice, 6th ed., 2020