Which component of the patient portal is the ability to see a doctor's availability? - Answers
Scheduling
Where would information about the patient's insulin dosage be found within the portal? - Answers
Medication 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? - Answers Closed-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? - Answers
Terminal-digit filing system
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? - Answers Discharge 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? - Answers 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? - Answers A physician should issue the
order in writing
Which component of the medical record does CMS CoP require to be completed no more than 30
days before or 24 hours after admission? - Answers History and physical
Which type of consent is a patient asked to sign prior to undergoing a scheduled gallbladder surgery?
- Answers Informed consent
Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg while
hospitalized? - Answers Medication administration record (MAR)
Which person's signature must be included on a consent form? - Answers Patient
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? - Answers CMS-
1500
Which guideline should an HIM professional use for documentation of both paper and electronic
records? - Answers The original documents should be maintained in the health record
Which type of information can be found in a physician's order? - Answers Written 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? - Answers Minimum 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? - Answers
Uniform Hospital Discharge Data Set (UHDDS)
Which data type is a cardiac catheterization examination note an example of? - Answers
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? - Answers Unstructured
Structured or Unstructured data: A zip code is entered and the state is automatically populated. -
Answers Structured
Structured or Unstructured data: PT chooses Therapy tab in the EHR and writes their treatment plan
notes. - Answers Structured
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 - Answers Structured
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? - Answers Compliance
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? - Answers
Transparency
, 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? -
Answers Disposition
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? - Answers Transparency
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?
- Answers Accountability
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? -
Answers Protection
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? - Answers Protection
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? - Answers Availability
Which term refers to the manner in which policy makers, data owners, data stewards, and other
stakeholders interact with each other? - Answers Rules of engagement
What does a stakeholder analysis of a data governance system identify? - Answers Needs of those
interested in the data
What is a best practice for data governance that should be incorporated into every program? -
Answers Specifying data quality requirements
Which organization requires cancer statistics to be reported from central registries to the national
organization responsible for cancer statistics? - Answers Centers for Disease Control and Prevention
(CDC)
Which organization requires reporting of medical malpractice payments, federal licensure and
certification actions, and adverse clinical privileges actions? - Answers National Practitioner Data
Bank (NPDB)
Which organization administers voluntary accreditation programs and provides deemed status to
certified hospitals and other healthcare organizations? - Answers The Joint Commission
What is the CMS external audit program that works to reduce MCR improper payments? - Answers
RACs
Which assessment do the CoP require all home health agencies to electronically report? - Answers
OASIS
To which organization must a sentinel event be reported? - Answers The Joint Commission
Which HIE architecture describes information that flows to more than one regional clinical data
repository (CDR) and requested records sent from one regional authority? - Answers Federated
Which HIE model supports uniformity of data, quick response times to queries, and consistency in
data accessibility? - Answers Centralized
A local SNF, hospital, and public health agency all participate in an HIE. The data is pushed from their
facilities into one repository where they all have access to retrieve data when needed. Which HIE
model is used in this scenario? - Answers Centralized
Which characteristic addresses the level of depth represented by data in a fact or dimension table in a
data warehouse? - Answers Granularity
Which quality describes data that is unaffected when used across all applications and systems? -
Answers Consistency
An HIM analyst is charged with reviewing abstracted information on opiod-related admissions from
the hospital's disease index database. The analyst wants to make sure that the correct ICD-10 codes
have been abstracted and pulled from the database. Which data quality characteristic does this
situation involve? - Answers Accuracy
An HIM director is auditing physician documentation and finds that 3% of the discharge summaries
from the last 6 months were completed more than 30 days past patient discharge. Which data quality
standard is an area of concern in this scenario? - Answers Timeliness