©Jason McConnel 2025 ALL RIGHTS RESERVED.
FOUNDATIONS IN HEALTHCARE DATA
MANAGEMENT. Exam Questions With
Correct Answers A+
A physician group is updating its electronic database system to allow patients to create profiles
and provide access to necessary individuals. Patients have the opportunity to access their
personal health information electronically from remote locations. The patients like being able to
see the doctor's open times to coordinate their schedules before requesting an office visit.Which
component of the patient portal is the ability to see a doctor's availability? - Answer✔Scheduling
A patient is admitted to an acute care facility while on vacation, but records from his physician's
office cannot be immediately obtained. The patient has difficulty remembering his insulin
dosage, but he recalls being enrolled in a patient portal.Where would information about the
patient's insulin dosage be found within this portal? - Answer✔Medication history
Which form of review is conducted after a patient is discharged from an acute care facility in
order to obtain information about trends and patterns of documentation? - Answer✔Closed-
record review
A hospital uses a filing system for permanent storage of paper-based health records. The records
are filed according to a three-part number made up of two-digit pairs. Which type of system is
this? - Answer✔Terminal-digit filing system
A patient goes to an emergency room complaining of chest pain and is released home four hours
later.Which type of documentation is required in this scenario? - Answer✔Discharge orders
A physician in an acute care facility is performing an H&P in accordance with the CMS
Conditions of Participation.Within how many days 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? - Answer✔30 days; 24 hours
A patient is ready to leave the emergency room but will need discharge orders before leaving.
How should the discharge orders be communicated to this patient? - Answer✔A physician
should issue the order in writing.
Which component of the medical record do the Centers for Medicare and Medicaid Services
(CMS) Conditions of Participation require to be completed no more than 30 days before or 24
hours after admission? - Answer✔History and physical
1|Page
, ©Jason McConnel 2025 ALL RIGHTS RESERVED.
Which type of consent is a patient asked to sign before undergoing a scheduled gallbladder
surgery? - Answer✔Informed consent
Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg while
hospitalized? - Answer✔Medication administration record
Which person's signature must be included on a consent form? - Answer✔Patient
In a physician's practice, a doctor is attempting to submit a claim to Medicare, but the system is
experiencing an outage.Which form should this doctor use to submit a paper claim? -
Answer✔CMS-1500
Which guideline should an health information management (HIM) professional follow for
documentation of both paper and electronic records? - Answer✔Original documents should be
maintained in the health record.
In which time frame should the history and physical be completed after a patient is admitted to
an inpatient healthcare facility? - Answer✔No more than 30 days before or 24 hours after
admission
Which type of information can be found in a physician's orders? - Answer✔Written or verbal
requests for treatment, tests, procedures, and medications
A nurse at a long-term care facility is documenting a comprehensive assessment into a patient's
medical record.What must the record include to meet Centers for Medicare and Medicaid
Services (CMS) requirements? - Answer✔Minimum Data Set (MDS)
A state hospital system is collecting information on inpatient discharges from hospitals in the
central part of a state.Which database should the hospital system use to collect this data? -
Answer✔Uniform Hospital Discharge Data Set (UHDDS)
Which data type is a cardiac catheterization examination note an example of? -
Answer✔Unstructured data
A paragraph in a physician's order specifies information about a patient's discharge. Which type
of data is described in this scenario? - Answer✔Unstructured
A nurse enters a patient's zip code, and the state is automatically populated. -
Answer✔Structured data
A physical therapist chooses the Therapy tab in the emergency health record and writes treatment
plan notes. - Answer✔Unstructured data
A nurse answers a question on an assessment screen in the emergency health record by clicking a
radio button in front of a Yes or a No. - Answer✔Structured data
A nurse adds a description of a patient's problem to the clinical assessment field. -
Answer✔Unstructured data
2|Page
FOUNDATIONS IN HEALTHCARE DATA
MANAGEMENT. Exam Questions With
Correct Answers A+
A physician group is updating its electronic database system to allow patients to create profiles
and provide access to necessary individuals. Patients have the opportunity to access their
personal health information electronically from remote locations. The patients like being able to
see the doctor's open times to coordinate their schedules before requesting an office visit.Which
component of the patient portal is the ability to see a doctor's availability? - Answer✔Scheduling
A patient is admitted to an acute care facility while on vacation, but records from his physician's
office cannot be immediately obtained. The patient has difficulty remembering his insulin
dosage, but he recalls being enrolled in a patient portal.Where would information about the
patient's insulin dosage be found within this portal? - Answer✔Medication history
Which form of review is conducted after a patient is discharged from an acute care facility in
order to obtain information about trends and patterns of documentation? - Answer✔Closed-
record review
A hospital uses a filing system for permanent storage of paper-based health records. The records
are filed according to a three-part number made up of two-digit pairs. Which type of system is
this? - Answer✔Terminal-digit filing system
A patient goes to an emergency room complaining of chest pain and is released home four hours
later.Which type of documentation is required in this scenario? - Answer✔Discharge orders
A physician in an acute care facility is performing an H&P in accordance with the CMS
Conditions of Participation.Within how many days 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? - Answer✔30 days; 24 hours
A patient is ready to leave the emergency room but will need discharge orders before leaving.
How should the discharge orders be communicated to this patient? - Answer✔A physician
should issue the order in writing.
Which component of the medical record do the Centers for Medicare and Medicaid Services
(CMS) Conditions of Participation require to be completed no more than 30 days before or 24
hours after admission? - Answer✔History and physical
1|Page
, ©Jason McConnel 2025 ALL RIGHTS RESERVED.
Which type of consent is a patient asked to sign before undergoing a scheduled gallbladder
surgery? - Answer✔Informed consent
Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg while
hospitalized? - Answer✔Medication administration record
Which person's signature must be included on a consent form? - Answer✔Patient
In a physician's practice, a doctor is attempting to submit a claim to Medicare, but the system is
experiencing an outage.Which form should this doctor use to submit a paper claim? -
Answer✔CMS-1500
Which guideline should an health information management (HIM) professional follow for
documentation of both paper and electronic records? - Answer✔Original documents should be
maintained in the health record.
In which time frame should the history and physical be completed after a patient is admitted to
an inpatient healthcare facility? - Answer✔No more than 30 days before or 24 hours after
admission
Which type of information can be found in a physician's orders? - Answer✔Written or verbal
requests for treatment, tests, procedures, and medications
A nurse at a long-term care facility is documenting a comprehensive assessment into a patient's
medical record.What must the record include to meet Centers for Medicare and Medicaid
Services (CMS) requirements? - Answer✔Minimum Data Set (MDS)
A state hospital system is collecting information on inpatient discharges from hospitals in the
central part of a state.Which database should the hospital system use to collect this data? -
Answer✔Uniform Hospital Discharge Data Set (UHDDS)
Which data type is a cardiac catheterization examination note an example of? -
Answer✔Unstructured data
A paragraph in a physician's order specifies information about a patient's discharge. Which type
of data is described in this scenario? - Answer✔Unstructured
A nurse enters a patient's zip code, and the state is automatically populated. -
Answer✔Structured data
A physical therapist chooses the Therapy tab in the emergency health record and writes treatment
plan notes. - Answer✔Unstructured data
A nurse answers a question on an assessment screen in the emergency health record by clicking a
radio button in front of a Yes or a No. - Answer✔Structured data
A nurse adds a description of a patient's problem to the clinical assessment field. -
Answer✔Unstructured data
2|Page
