C810 QUESTIONS AND ANSWERS
100% CORRECT
Which component of the patient portal is the ability to see a doctor's availability? -
ANSWERScheduling
Where would information about the patient's insulin dosage be found within the
portal? - ANSWERMedication history
Which form of review is conducted following the discharge of a patient from an acute
care facility to obtain information about trends and patterns of documentation? -
ANSWERClosed-record review
A hospital uses a filing 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? - ANSWERTerminal-digit filing system
Which component of the medical record does CMS CoP require to be completed no
more than 30 days before or 24 hours after admission? - ANSWERHistory and
physical
Which type of consent is a patient asked to sign prior to undergoing a scheduled
gallbladder surgery? - ANSWERInformed consent
Where does a nurse document that a patient is given an oral dose of Coumadin 1
mg while hospitalized? - ANSWERMedication administration record (MAR)
Which person's signature must be included on a consent form? - ANSWERPatient
In a physician's practice, 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? - ANSWERCMS-1500
Which guideline should an HIM professional use for documentation of both paper
and electronic records? - ANSWERThe original documents should be maintained in
the health record
Which type of information can be found in a physician's order? - ANSWERWritten or
verbal requests for treatment, tests, procedures, and medications
A nurse at a long-term care facility is documenting a comprehensive assessment into
the patient's medical record. What must the record include to meet CMS
requirements? - ANSWERMinimum Data Set (MDS)
A state hospital system 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? - ANSWERUniform Hospital Discharge Data Set (UHDDS)
,Which data type is a cardiac catheterization examination note an example of? -
ANSWERUnstructured data
A paragraph in a physician's order specifies information about a patient's discharge.
Which type of data is described in this scenario? - ANSWERUnstructured
Structured or Unstructured data: A zip code is entered and the state is automatically
populated. - ANSWERStructured
Structured or Unstructured data: PT chooses Therapy tab in the EHR and writes
their treatment plan notes. - ANSWERStructured
Structured or Unstructured data: Nurse answers a question on an assessment
screen in the EHR by clicking a radial button in front of a Yes or a No -
ANSWERStructured
A patient went to the emergency room complaining of chest pain and was released
home 4 hours later. Which type of documentation is required in this scenario? -
ANSWERDischarge orders
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? -
ANSWER30 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? -
ANSWERA physician should issue the order in writing
The HIM director and the CIO have been asked to update the healthcare system's
data governance strategic plan. In particular, they are working on standardizing data
governance language across the healthcare system and ensuring that they meed
data regulations and mandates. Which information governance principle is described
in this scenario? - ANSWERCompliance
A hospital is informing the Infection Control Committee about the number of
postoperative infections it had during a given time period. Which principle for
governance is used in this scenario? - ANSWERTransparency
A health information manager is responsible for properly destroying records after the
retention period has passed. Which principle for information governance is described
in this scenario? - ANSWERDisposition
A communication plan is being developed to reduce mistrust and miscommunication
in a healthcare setting. In addition to open communication, which other principle for
information governance must be considered when developing this plan? -
ANSWERTransparency
, A data governance steering committee is formed and tasked with developing the
goals of the data governance program. Which generally accepted record-keeping
principle is described in the scenario? - ANSWERAccountability
A HIM director has been informed of potential data security violations. The HIM
director asks one of the health informatics analysts to work with the CIO to monitor
the audit trails of the EHR to identify any violations. Which generally accepted
record-keeping principle is described in this scenario? - ANSWERProtection
The CIO is working to improve data security methodologies within the EHR. The CIO
enlists the help of the HIM director to help design and enforce the new data security
policies, which include the utilization of a new token system to access the EHR.
Which information governance principle is described in this scenario? -
ANSWERProtection
In a healthcare facility that still uses paper records, a physician is requesting a
record to complete a discharge summary that is now 28 days past due. The record
tracker states that the record has been sent to storage. Which record keeping
principle would apply to this scenario? - ANSWERAvailability
Which term refers to the manner in which policy makers, data owners, data
stewards, and other stakeholders interact with each other? - ANSWERRules of
engagement
What does a stakeholder analysis of a data governance system identify? -
ANSWERNeeds of those interested in the data
What is a best practice for data governance that should be incorporated into every
program? - ANSWERSpecifying data quality requirements
Which organization requires cancer statistics to be reported from central registries to
the national organization responsible for cancer statistics? - ANSWERCenters for
Disease Control and Prevention (CDC)
Which organization requires reporting of medical malpractice payments, federal
licensure and certification actions, and adverse clinical privileges actions? -
ANSWERNational Practitioner Data Bank (NPDB)
Which organization administers voluntary accreditation programs and provides
deemed status to certified hospitals and other healthcare organizations? -
ANSWERThe Joint Commission
What is the CMS external audit program that works to reduce MCR improper
payments? - ANSWERRACs
Which assessment do the CoP require all home health agencies to electronically
report? - ANSWEROASIS
To which organization must a sentinel event be reported? - ANSWERThe Joint
Commission
100% CORRECT
Which component of the patient portal is the ability to see a doctor's availability? -
ANSWERScheduling
Where would information about the patient's insulin dosage be found within the
portal? - ANSWERMedication history
Which form of review is conducted following the discharge of a patient from an acute
care facility to obtain information about trends and patterns of documentation? -
ANSWERClosed-record review
A hospital uses a filing 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? - ANSWERTerminal-digit filing system
Which component of the medical record does CMS CoP require to be completed no
more than 30 days before or 24 hours after admission? - ANSWERHistory and
physical
Which type of consent is a patient asked to sign prior to undergoing a scheduled
gallbladder surgery? - ANSWERInformed consent
Where does a nurse document that a patient is given an oral dose of Coumadin 1
mg while hospitalized? - ANSWERMedication administration record (MAR)
Which person's signature must be included on a consent form? - ANSWERPatient
In a physician's practice, 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? - ANSWERCMS-1500
Which guideline should an HIM professional use for documentation of both paper
and electronic records? - ANSWERThe original documents should be maintained in
the health record
Which type of information can be found in a physician's order? - ANSWERWritten or
verbal requests for treatment, tests, procedures, and medications
A nurse at a long-term care facility is documenting a comprehensive assessment into
the patient's medical record. What must the record include to meet CMS
requirements? - ANSWERMinimum Data Set (MDS)
A state hospital system 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? - ANSWERUniform Hospital Discharge Data Set (UHDDS)
,Which data type is a cardiac catheterization examination note an example of? -
ANSWERUnstructured data
A paragraph in a physician's order specifies information about a patient's discharge.
Which type of data is described in this scenario? - ANSWERUnstructured
Structured or Unstructured data: A zip code is entered and the state is automatically
populated. - ANSWERStructured
Structured or Unstructured data: PT chooses Therapy tab in the EHR and writes
their treatment plan notes. - ANSWERStructured
Structured or Unstructured data: Nurse answers a question on an assessment
screen in the EHR by clicking a radial button in front of a Yes or a No -
ANSWERStructured
A patient went to the emergency room complaining of chest pain and was released
home 4 hours later. Which type of documentation is required in this scenario? -
ANSWERDischarge orders
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? -
ANSWER30 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? -
ANSWERA physician should issue the order in writing
The HIM director and the CIO have been asked to update the healthcare system's
data governance strategic plan. In particular, they are working on standardizing data
governance language across the healthcare system and ensuring that they meed
data regulations and mandates. Which information governance principle is described
in this scenario? - ANSWERCompliance
A hospital is informing the Infection Control Committee about the number of
postoperative infections it had during a given time period. Which principle for
governance is used in this scenario? - ANSWERTransparency
A health information manager is responsible for properly destroying records after the
retention period has passed. Which principle for information governance is described
in this scenario? - ANSWERDisposition
A communication plan is being developed to reduce mistrust and miscommunication
in a healthcare setting. In addition to open communication, which other principle for
information governance must be considered when developing this plan? -
ANSWERTransparency
, A data governance steering committee is formed and tasked with developing the
goals of the data governance program. Which generally accepted record-keeping
principle is described in the scenario? - ANSWERAccountability
A HIM director has been informed of potential data security violations. The HIM
director asks one of the health informatics analysts to work with the CIO to monitor
the audit trails of the EHR to identify any violations. Which generally accepted
record-keeping principle is described in this scenario? - ANSWERProtection
The CIO is working to improve data security methodologies within the EHR. The CIO
enlists the help of the HIM director to help design and enforce the new data security
policies, which include the utilization of a new token system to access the EHR.
Which information governance principle is described in this scenario? -
ANSWERProtection
In a healthcare facility that still uses paper records, a physician is requesting a
record to complete a discharge summary that is now 28 days past due. The record
tracker states that the record has been sent to storage. Which record keeping
principle would apply to this scenario? - ANSWERAvailability
Which term refers to the manner in which policy makers, data owners, data
stewards, and other stakeholders interact with each other? - ANSWERRules of
engagement
What does a stakeholder analysis of a data governance system identify? -
ANSWERNeeds of those interested in the data
What is a best practice for data governance that should be incorporated into every
program? - ANSWERSpecifying data quality requirements
Which organization requires cancer statistics to be reported from central registries to
the national organization responsible for cancer statistics? - ANSWERCenters for
Disease Control and Prevention (CDC)
Which organization requires reporting of medical malpractice payments, federal
licensure and certification actions, and adverse clinical privileges actions? -
ANSWERNational Practitioner Data Bank (NPDB)
Which organization administers voluntary accreditation programs and provides
deemed status to certified hospitals and other healthcare organizations? -
ANSWERThe Joint Commission
What is the CMS external audit program that works to reduce MCR improper
payments? - ANSWERRACs
Which assessment do the CoP require all home health agencies to electronically
report? - ANSWEROASIS
To which organization must a sentinel event be reported? - ANSWERThe Joint
Commission
