C810 - Foundations of Data Management
Exam Questions and Answers 100%
Solved
What is a health record? - ✔✔A complete, accurate, and current report of
the medical history, condition, and treatment that a particular patient
receives during an inpatient or outpatient encounter with a healthcare
provider
True or False?
The health record may reflect one episode of care or an accumulation of all
episodes of care (longitudinal record) - ✔✔True
What is included in demographic information collected at time of admission
or registration for treatment? - ✔✔- Name
- Sex
- Age
- Insurance information
- Emergency contacts
1
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
,What is included in clinical information? - ✔✔- Patient's complaint
- History of present illness
- Medical history
- Family history
- Social history
- Physician progress notes and orders
- Reports of diagnostic tests
- Surgery and other procedure reports
- Nursing documentation
- Final diagnosis(es)
What is the rentention of the health record? - ✔✔- The retention period
refers to how long health records must be kept
- The health record serves several purposes and must be retained to meet
them
- Such purposes include patient treatment, proof of services provided to
justify reimbursement and evidence in legal proceedings
- Federal and state statutes and regulations often determine retention
periods
Who owns the health record? - ✔✔- The organization that creates and
maintains the physical record is the legal custodian and is legally
2
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
, responsible for all aspects of it, including its integrity, security and
completeness
- Although the organization owns the record, patients have the right to
access the record with exceptions noted in HIPAA
What is express consent? - ✔✔- Consent communicated through words,
either written or spoken
What is implied consent? - ✔✔- Consent communicated through conduct or
a mechanism other than words
What is informed consent? - ✔✔- Ensures the patient has a basic
understanding of his or her diagnosis; the nature of the treatment or
procedure along with the risks, benefits, and alternatives; and individuals
who will perform the treatment or procedure
- The document must be signed and dated by the patient, the provider
rendering the treatment, and a witness
What is advance directive? - ✔✔A special type of written consent that
communicates an individual's wishes to be treated or not treated should the
individual become incapacitated and unable to communicate on his or her
own behalf
3
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
Exam Questions and Answers 100%
Solved
What is a health record? - ✔✔A complete, accurate, and current report of
the medical history, condition, and treatment that a particular patient
receives during an inpatient or outpatient encounter with a healthcare
provider
True or False?
The health record may reflect one episode of care or an accumulation of all
episodes of care (longitudinal record) - ✔✔True
What is included in demographic information collected at time of admission
or registration for treatment? - ✔✔- Name
- Sex
- Age
- Insurance information
- Emergency contacts
1
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
,What is included in clinical information? - ✔✔- Patient's complaint
- History of present illness
- Medical history
- Family history
- Social history
- Physician progress notes and orders
- Reports of diagnostic tests
- Surgery and other procedure reports
- Nursing documentation
- Final diagnosis(es)
What is the rentention of the health record? - ✔✔- The retention period
refers to how long health records must be kept
- The health record serves several purposes and must be retained to meet
them
- Such purposes include patient treatment, proof of services provided to
justify reimbursement and evidence in legal proceedings
- Federal and state statutes and regulations often determine retention
periods
Who owns the health record? - ✔✔- The organization that creates and
maintains the physical record is the legal custodian and is legally
2
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
, responsible for all aspects of it, including its integrity, security and
completeness
- Although the organization owns the record, patients have the right to
access the record with exceptions noted in HIPAA
What is express consent? - ✔✔- Consent communicated through words,
either written or spoken
What is implied consent? - ✔✔- Consent communicated through conduct or
a mechanism other than words
What is informed consent? - ✔✔- Ensures the patient has a basic
understanding of his or her diagnosis; the nature of the treatment or
procedure along with the risks, benefits, and alternatives; and individuals
who will perform the treatment or procedure
- The document must be signed and dated by the patient, the provider
rendering the treatment, and a witness
What is advance directive? - ✔✔A special type of written consent that
communicates an individual's wishes to be treated or not treated should the
individual become incapacitated and unable to communicate on his or her
own behalf
3
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
