2025/2026
Exam Prep Guide
(Expert Verified Questions and
Answers)
Plus A+ Grade Guarantee
1. Which component of the
Scheduling patient portal is the
ability to see a doctor's
availability?
2. Where would informa-
Medication history tion about
the patient's insulin dosage be
found within the portal?
3. Which form of review is Closed-
record review conducted
following the discharge of a
patient from an acute care
facility to obtain information
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about trends and patterns of
documentation?
4. A hospital uses a fil- Terminal-
digit filing system ing system for
permanent storage of paper-
based records. The records are
filed according to a three-part
number made up of two-digit
parts. What type of system is
this?
5. A patient went to the
Discharge orders emergency
room complaining of chest pain
and was released home
4 hours later. Which
type of documentation
is required in this
scenario?
6. Within how many days 30
days 24 hours prior to admission
must the H&P be performed and
within how many hours must the
H&P be placed in the patient's
record after admission?
7. A patient is ready to A physician
should issue the order in writing
leave the emergency room but
will need discharge orders before
leaving. How should the
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discharge orders be
communicated to this patient?
8. Which component of History and
physical the medical record does
CMS CoP require to be
completed no more than 30 days
before or 24 hours after
admission?
9. Which type of consent Informed
consent is a patient asked to
sign prior to undergoing a
scheduled gallbladder surgery?
10. Where does a nurse doc-
Medication administration record
(MAR) ument that a patient is
given an oral dose of
Coumadin 1 mg while
hospitalized?
11. Which person's signa- Patient
ture must be included on a
consent form?
12. In a physician's practice, CMS-
1500 a doctor is attempting to
submit a claim to MCR, but the
system is experiencing an
outage. Which form would this
doctor use to submit a paper
claim?
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13. Which guideline should The
original documents should be
maintained in the health record
an HIM professional
use for documentation
of both paper and
electronic records?
14. Which type of informa- Written
or verbal requests for treatment,
tests, procedures, and medtion
can be found in a ications
physician's order?
15. A nurse at a long-term Minimum
Data Set (MDS) care facility is
documenting a comprehensive
as-
sessment into the
patient's medical
record. What must the
record include to meet
CMS requirements?
16. A state hospital system Uniform
Hospital Discharge Data Set
(UHDDS) is collecting
information on patient
discharges from hospitals in the
central part of the state. Which
databases should the hospital
system use to collect this data?
2025/2026