22 Health Records & Data Content Practice Questions & Answers

1. 1. A health information technician reviews every discharged inpatient record to confirm that the history and physical, the operative report and the discharge summary are present, and that each entry is signed and dated by its author. This review is best described as:

   • A.Qualitative analysis, confirming that the narrative content of the reports agrees with itself
   • B.Quantitative analysis, confirming that the required reports are present, signed and dated✓ Answer
   • C.Concurrent coding review, confirming that each code assigned has support in the record
   • D.Utilization review, confirming that the level of care matched the severity of the illness

   Quantitative analysis is the completeness check: it asks whether every report required by policy or regulation is in the record and whether each entry is authenticated with a signature and a date. It never judges what the documentation actually says, which is the separate work of qualitative analysis.

   Source: AHIMA CCA Exam Content Outline (2022), Domain 3, Task 3.2 (quantitative analysis for record completeness)Report a problem with this question

2. 2. A record review finds that the discharge summary lists congestive heart failure as a discharge diagnosis, while the progress notes, the medication record and the orders for the entire stay address only pneumonia. Detecting this kind of internal contradiction is the purpose of:

   • A.Record assembly, because the reports of the encounter were filed out of the facility's standard order
   • B.Productivity monitoring, because the chart took the coder longer than the departmental time standard
   • C.Qualitative analysis, because the documented content does not agree with the rest of the record✓ Answer
   • D.Quantitative analysis, because an entry in the record has been left without a signature and date

   Qualitative analysis looks at what the documentation says rather than whether it is present: it tests the record for internal consistency and for whether the entries support one another. A diagnosis that appears only in the discharge summary and is contradicted by the rest of the stay is exactly the finding qualitative review exists to surface.

   Source: AHIMA CCA Exam Content Outline (2022), Domain 3, Task 3.3 (qualitative analysis for documentation deficiencies)Report a problem with this question

3. 3. A hospital's medical staff rules require records to be completed within 14 days of discharge. Twenty-one days after discharge, one record still lacks the physician's signature on the discharge summary. In incomplete record management, this record is counted as:

   • A.An incomplete record that is not yet delinquent, because only a signature is outstanding
   • B.A suspended record, because the coder could not finish assigning codes from the chart
   • C.A discharged-not-final-billed account, because the chart has not been released to billing
   • D.A delinquent record, because it is incomplete past the medical staff deadline✓ Answer

   A deficiency is any missing report, signature or date, and the record holding it is incomplete. It becomes delinquent the moment it passes the completion deadline set by medical staff rules and accreditation requirements, and the delinquent record rate is the measure the facility tracks and reports.

   Source: Medicare Conditions of Participation 42 CFR 482.24(c); AHIMA incomplete/delinquent record managementReport a problem with this question

4. 4. A patient arrives in the pre-operative area for elective surgery and the chart contains no history and physical. Under the Medicare Conditions of Participation, what must be in place before the procedure begins?

   • A.The anesthesia pre-sedation evaluation, which serves as the history and physical for surgery
   • B.The admitting nurse's assessment, which substitutes when the surgery is elective and routine
   • C.A completed history and physical in the record, with a note updating any change in condition✓ Answer
   • D.The surgeon's statement that the history and physical will be dictated once the case ends

   The Conditions of Participation require a history and physical completed no more than 30 days before or 24 hours after admission or registration and placed in the record before surgery; when it was done earlier, an update note documenting any change in the patient's condition is required. No other report substitutes for it.

   Source: 42 CFR 482.24(c)(4)(i) and 42 CFR 482.51(b)(1) (history and physical before surgery)Report a problem with this question

5. 5. A surgeon finishes an operation and the dictated operative report will not be transcribed and filed until the following day. What does the documentation standard require of the record in the meantime?

   • A.An addendum to the history and physical stating that the planned procedure was carried out
   • B.The anesthesia record, which serves as the operative documentation until the report is filed
   • C.The circulating nurse's intraoperative record, countersigned by the surgeon before leaving
   • D.An immediate postoperative note giving the findings, the procedure and the specimens removed✓ Answer

   The operative report is dictated or written immediately after surgery, and when the full report is not yet available in the record a brief postoperative progress note must be entered at once so that the next caregiver knows what was found, what was done and what tissue was sent.

   Source: 42 CFR 482.51(b)(6) (operative report written or dictated immediately; brief postoperative note)Report a problem with this question

6. 6. A coder needs the one report that states the reason for the admission, the significant findings, the procedures and treatment given, the patient's condition at discharge and the follow-up plan. Which report is designed to carry all of that?

   • A.The history and physical, which records the admitting findings and the initial plan of care
   • B.The operative report, which describes the procedure performed and the specimens submitted
   • C.The consultation report, which records another physician's opinion on a specific problem
   • D.The discharge summary, which recaps the stay and the patient's condition at release✓ Answer

   The discharge summary is the recapitulation of the entire inpatient stay and is required to state the reason for hospitalization, the significant findings, the procedures and treatment provided, the condition at discharge and the instructions for follow-up, which is why coders read it first for the overall picture.

   Source: 42 CFR 482.24(c)(4)(viii) (discharge summary content); AHIMA record content standardsReport a problem with this question

7. 7. The pathology report on an excised skin lesion reads basal cell carcinoma. The operative report and every progress note describe only 'skin lesion, excised', and no treating provider names a malignancy anywhere in the record. What should the coder do?

   • A.Assign a lesion of uncertain behavior, because the pathology and the operative note conflict
   • B.Assign the malignancy from the pathology report, since a pathologist is a physician who saw the tissue
   • C.Obtain documentation of the diagnosis from the treating provider before coding the malignancy✓ Answer
   • D.Assign the malignancy and record the pathology report as the source on the abstracting screen

   Code assignment rests on the documentation of the provider legally accountable for the diagnosis, so a pathologist's finding does not by itself establish a diagnosis for coding. The finding is a signal to seek the treating provider's documentation, not a substitute for it.

   Source: ICD-10-CM Official Guidelines, Section I.A/I.B (code assignment based on the provider's documentation)Report a problem with this question

8. 8. A chest radiograph report signed by the radiologist states 'findings consistent with pneumonia.' The attending physician's admission note and progress notes document cough and fever and never mention pneumonia. How is pneumonia handled for code assignment?

   • A.It is not coded from the imaging report alone; the treating provider must document the diagnosis✓ Answer
   • B.It may be coded, because an inpatient record allows a diagnosis documented as consistent with
   • C.It may be coded, because the radiologist is a physician whose interpretation stands on its own
   • D.It is coded as a secondary diagnosis, with the cough and the fever sequenced ahead of it

   A radiologist's interpretation is diagnostic test information, not the treating provider's diagnostic statement, so an abnormal finding cannot be coded as a confirmed condition on its own. The inpatient rule about probable or consistent-with wording applies to the treating provider's documentation, not to the imaging report.

   Source: ICD-10-CM Official Guidelines, Section I.A/I.B and Section II.H (provider documentation required for diagnosis)Report a problem with this question

9. 9. A dietitian's note records the patient's body mass index and a wound care nurse's note records the stage of a pressure ulcer. Neither clinician is the treating provider. How may the coder use these two entries?

   • A.The values may be taken from those notes and are enough on their own to report the diagnosis
   • B.The values may not be used at all unless the provider repeats the number in a progress note
   • C.The values may be taken from those notes, but the provider must document the related diagnosis✓ Answer
   • D.The values may be used only after the provider countersigns each of the two clinicians' notes

   The guidelines allow a limited set of values, such as body mass index, coma scale scores and pressure ulcer stages, to be taken from clinicians who are not the patient's provider, because those are measurements rather than diagnoses. The underlying condition itself still has to be documented by the provider before any code is assigned.

   Source: ICD-10-CM Official Guidelines, Section I.B.14 (documentation by clinicians other than the patient's provider)Report a problem with this question

10. 10. After coding a discharge, a technician keys the admission and discharge dates, the discharge disposition, the attending and operating physician identifiers and the assigned codes into the facility's data system. This activity is:

    • A.Data abstraction, capturing defined data elements from the record into the facility's systems✓ Answer
    • B.Data mapping, translating the concepts of one code set into their equivalents in another
    • C.Record assembly, arranging the reports of the encounter into the facility's standard order
    • D.Chart analysis, verifying that every report required for the encounter is present and signed

    Abstracting is the transfer of defined data elements out of the narrative record and into structured fields, and the inpatient element list follows the discharge data set: dates, disposition, physician identifiers, diagnoses and procedures. Those fields then feed billing, statistics and required external reporting.

    Source: AHIMA CCA Exam Content Outline (2022), Domain 3, Task 3.4 (data abstraction); UHDDS data elementsReport a problem with this question

11. 11. An audit finds that an abstractor entered the wrong discharge disposition on a series of accounts. What is the most accurate statement about the effect of that error?

    • A.It carries into the statistics, reports and claims that draw on the abstracted disposition✓ Answer
    • B.It stays inside the abstract and changes nothing, because reports are built from the codes
    • C.It matters only for transfers, because disposition is unused for routine discharges home
    • D.It is corrected on its own when the grouper recalculates the account from the coded data

    Abstracted fields are the source of everything downstream: the claim, the statistical reports, the quality submissions and the internal dashboards all read the same stored values. An error introduced at abstraction is therefore reproduced everywhere the field is used until it is found and corrected.

    Source: AHIMA Data Quality Management Model (accuracy); AHIMA CCA Content Outline Domain 3, Task 3.4Report a problem with this question

12. 12. What is the master patient index maintained to do?

    • A.Link each patient to one unique record number and list that patient's encounters there✓ Answer
    • B.Track the deficiencies outstanding on each incomplete record and the physician responsible
    • C.Hold the clinical content of every encounter so records can be retrieved by diagnosis
    • D.Log every disclosure of protected health information made for a purpose other than treatment

    The master patient index is the permanent link between a person and the single medical record number assigned to that person, together with a list of the encounters filed under it. It is an index rather than a repository, which is why its integrity governs whether the right chart is retrieved.

    Source: AHIMA practice brief on managing the integrity of patient identity; CCA Content Outline Domain 3, Task 3.6Report a problem with this question

13. 13. A registrar merges two index entries believing them to be the same person. The resulting record now holds the clinical information of two different patients under one record number. This error is called:

    • A.A duplicate, in which one patient has been given more than one number at the same facility
    • B.An overlap, in which one patient carries different numbers at two facilities in one system
    • C.An overlay, in which one patient's information is filed inside another's record✓ Answer
    • D.A purge, in which an inactive record is moved out of the active file under retention policy

    An overlay places one person's clinical information inside another person's record, so a clinician reading that chart sees allergies, results and history that belong to someone else. It is treated as the most dangerous identity error precisely because it can drive a wrong clinical decision.

    Source: AHIMA practice brief on patient identity integrity (duplicate, overlap and overlay definitions)Report a problem with this question

14. 14. An integrity audit shows that one patient holds two medical record numbers at the same facility, with encounters split between them. What is the appropriate handling?

    • A.Resolve the index to one number and reconcile the encounters under it✓ Answer
    • B.Delete the number with fewer encounters so that only one number remains in the index
    • C.Keep both numbers active and flag each one so that staff also check the other number
    • D.Issue a third new number and file every future encounter for that patient under it

    A duplicate is remediated by resolving the identity so that the patient has one number going forward and the clinical information from both files is available under it. Clinical documentation is never deleted in the process, because the entries remain part of the legal record of those encounters.

    Source: AHIMA practice brief on patient identity integrity (duplicate resolution)Report a problem with this question

15. 15. Records from an outside physician's office are scanned into the chart for the current admission. One outside note documents a chronic condition that no clinician has addressed during this stay. May the coder assign that diagnosis for this admission?

    • A.Yes, provided the outside note carries the signature and the date of the physician who wrote it
    • B.Yes, because any document filed in the record of the encounter is available for code assignment
    • C.No, because a provider treating the patient during this encounter must document the diagnosis✓ Answer
    • D.No, because outside records may not be scanned into the chart or used by coding at all

    Outside documentation can be requested and filed for clinical reference, and it is a legitimate reason to seek clarification, but codes for an encounter rest on what a provider treating the patient during that encounter documents. Scanning a document into the chart does not make it that provider's diagnostic statement.

    Source: ICD-10-CM Official Guidelines, Section I.A/I.B; AHIMA CCA Content Outline Domain 3, Task 3.5Report a problem with this question

16. 16. A physician enters a progress note in the electronic health record and applies an electronic signature. In health record documentation, what does authentication establish?

    • A.That the entry has been filed under the correct patient's record number and encounter
    • B.That the author of the entry is identified and takes responsibility for its content✓ Answer
    • C.That the terms used in the entry match the facility's list of approved abbreviations
    • D.That every report required for the encounter has been placed in the assembled chart

    Authentication means the entry is attributed to a named author who is accountable for what it says, by signature, initials or a unique electronic credential. It is why an unsigned entry counts as a deficiency and why credentials are never shared between users.

    Source: 42 CFR 482.24(c)(1) (entries authenticated by the person responsible for the order or care)Report a problem with this question

17. 17. A nurse realizes that a note written earlier in the shift was entered in the wrong patient's paper record. What is the correct way to handle that entry?

    • A.Remove the sheet from the record, destroy it, and document again in the correct chart
    • B.Strike the entry with a single line, mark it as an error, and sign and date the correction✓ Answer
    • C.Cover the entry with correction fluid and rewrite the note in the correct patient's chart
    • D.Leave the entry as written and put a note in the other chart explaining where the error is

    A correction must leave the original entry readable, because the record is a legal document and what was originally written, and when, may matter later. The accepted method marks the entry as an error and identifies who corrected it and when, and the same principle governs an amendment in an electronic record.

    Source: AHIMA practice brief on amendments, corrections and deletions in the health recordReport a problem with this question

18. 18. Audits show that hospitalists routinely document only 'heart failure' with no further detail, and the HIM department is asked to run an education session. Which approach is appropriate?

    • A.Distribute the list of diagnoses that group to a higher weight and ask that those be written
    • B.Have the coders write the specific diagnosis in the note and ask the physician to countersign
    • C.Explain which clinical details make the documentation specific, without dictating a diagnosis✓ Answer
    • D.Direct the physicians to document the most specific condition on the differential every time

    Provider education teaches what clinical detail the classification needs, such as acuity, type and any stated causal link, and leaves the clinical conclusion to the clinician. Material built around which diagnoses pay more, or having someone else write the diagnosis for a signature, leads the documentation instead of improving it.

    Source: AHIMA CCA Content Outline Domain 3, Task 3.7 (educate providers on health data standards); AHIMA Standards of Ethical CodingReport a problem with this question

19. 19. Over two quarters the case mix index of a hospital's medical service falls steadily while the patient population and its severity have not changed. What is the most reasonable first interpretation?

    • A.Outpatient volume rose in the same period, which dilutes the average across all accounts
    • B.Documentation or the capture of secondary conditions may have weakened and needs review✓ Answer
    • C.The coders handled fewer charts per day, which lowers the average weight of the case group
    • D.The hospital's base payment rate was cut, which lowers the index calculated for each discharge

    Case mix index is the average relative weight of the groups assigned to a facility's discharges, so it moves with what is documented and coded, not with payment rates or with how fast charts are processed. A drop with unchanged acuity points to lost specificity or missed secondary conditions.

    Source: AHIMA CCA Content Outline Domain 3, Task 3.8 (interpret coding data reports); case mix index definitionReport a problem with this question

20. 20. A revenue cycle report shows the discharged-not-final-billed total climbing week over week. What does that figure represent?

    • A.Accounts of discharged patients not yet billed, often waiting for coding to be finished✓ Answer
    • B.Records of discharged patients still missing a signature needed to complete the chart
    • C.Encounters already coded but held because documentation did not support the service
    • D.Claims already transmitted that the payer rejected before they entered adjudication

    Discharged not final billed measures accounts that have left the building but have not yet dropped a bill, and coding is one of the most common places they wait, whether for coder capacity or for missing documentation. Rising totals are read as cash sitting still, which is why coding managers watch the report.

    Source: AHIMA CCA Content Outline Domain 3, Task 3.8 (interpret coding data reports); DNFB definitionReport a problem with this question

21. 21. A coding manager's monthly report shows one coder well above the department's charts-per-hour standard while that coder's audit accuracy rate sits well below the department's threshold. What is the sound reading of the two figures together?

    • A.Speed is outrunning accuracy, so the review should look at what is missed and why✓ Answer
    • B.The accuracy rate describes the whole department and cannot be read for one coder
    • C.The audit sample must be flawed, because a higher volume yields more correct codes
    • D.Volume above standard offsets the accuracy result, so no further review is warranted

    Productivity and accuracy are read together because either one alone is misleading: charts per hour says how much work moved, and the audit rate says whether the coded data are right. High volume with low accuracy points to rushed review of the documentation, which is a coaching and re-audit situation.

    Source: AHIMA CCA Content Outline Domain 3, Task 3.8 (interpret coding data reports); coding quality monitoringReport a problem with this question

22. 22. A facility is setting the retention period for adult inpatient health records. Which statement should drive that policy?

    • A.The period is left to the facility alone, since retaining records is a business matter
    • B.The period comes from state law and federal requirements, and policy meets the longest✓ Answer
    • C.The period is set by the accrediting body, whose standard prevails over state law
    • D.The period is fixed nationally by HIPAA at one number that applies to every provider

    Retention of the health record is governed by state law and by federal program requirements, and where they differ the policy has to satisfy the longest applicable period, with statutes of limitation and minors' records extending it further. HIPAA sets a retention period for its own compliance documentation, not for medical records.

    Source: 42 CFR 482.24(b)(1) (Medicare record retention); state retention law; AHIMA retention and destruction practice briefReport a problem with this question

Practice questions based on the AHIMA Certified Coding Associate (CCA) Exam Content Outline, the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, and the AHIMA Standards of Ethical Coding. This site is not affiliated with or endorsed by AHIMA. Code sets and their official guidelines are revised every year, so no question here keys a specific code value — always assign codes from the current code books, encoder and official guidelines in effect for the date of service, never from a practice test. Confirm current eligibility and exam requirements with AHIMA before you test. About the CCA credential →