WGU C810 Foundations in
Healthcare Data Management-
Advance Exam Prep Questions
with Correct Answers (VERIFIED)
History and Physical (H&P)—ANSWER--Must be completed within 24 hours of admission.
Documentation issue—ANSWER--Absence of objective measurable information.
Agency citation—ANSWER--CMS is most likely to cite the facility for a forgotten signature on
an order.
Advance Directive (DNR)—ANSWER--Best document to support a patient's decision to refuse
CPR.
Consultation report—ANSWER--Contains detailed assessments from specialists.
Hybrid record—ANSWER--Primary classification for records that include both paper and
electronic formats.
Patient safety concern—ANSWER--Incorrect drug administration is the most immediate
concern when documentation is missing from the MAR.
History and Physical—ANSWER--Document that must include the patient's chief complaint,
past medical history, and review of systems.
, Documentation standards—ANSWER--First correct action for an incorrect blood pressure
entry is to draw a line through the error and initial/date it.
Approved-abbreviation policy—ANSWER--Requirement likely violated if confusing and
inconsistent abbreviations are used in MAR entries.
Patient/member web portal—ANSWER--Feature that supports patients accessing their lab
results.
SOAP notes—ANSWER--The Assessment portion contains the provider's clinical judgment.
Documentation requirement—ANSWER--Completeness and dating requirements are
violated when daily progress notes are missing timestamps.
Inpatient discharge summary—ANSWER--Must include final diagnoses and outcome to meet
documentation standards.
Scanned faxes—ANSWER--Classified as secondary data once stored electronically.
EMR artifacts—ANSWER--Part of the electronic content management system
Unreviewable external documentation—ANSWER--Documentation that cannot be reviewed
for accuracy or compliance
Late entry—ANSWER--An entry made after the event has occurred, which must be clearly
identified
H&P—ANSWER--History and Physical, a document that records a patient's medical history
and physical examination findings
MAR—ANSWER--Medication Administration Record, a document that tracks medications
administered to a patient
© 2026 Copyright. All Rights Reserved. This document is
protected by copyright law, Copyrighted By Brittie Donald
Healthcare Data Management-
Advance Exam Prep Questions
with Correct Answers (VERIFIED)
History and Physical (H&P)—ANSWER--Must be completed within 24 hours of admission.
Documentation issue—ANSWER--Absence of objective measurable information.
Agency citation—ANSWER--CMS is most likely to cite the facility for a forgotten signature on
an order.
Advance Directive (DNR)—ANSWER--Best document to support a patient's decision to refuse
CPR.
Consultation report—ANSWER--Contains detailed assessments from specialists.
Hybrid record—ANSWER--Primary classification for records that include both paper and
electronic formats.
Patient safety concern—ANSWER--Incorrect drug administration is the most immediate
concern when documentation is missing from the MAR.
History and Physical—ANSWER--Document that must include the patient's chief complaint,
past medical history, and review of systems.
, Documentation standards—ANSWER--First correct action for an incorrect blood pressure
entry is to draw a line through the error and initial/date it.
Approved-abbreviation policy—ANSWER--Requirement likely violated if confusing and
inconsistent abbreviations are used in MAR entries.
Patient/member web portal—ANSWER--Feature that supports patients accessing their lab
results.
SOAP notes—ANSWER--The Assessment portion contains the provider's clinical judgment.
Documentation requirement—ANSWER--Completeness and dating requirements are
violated when daily progress notes are missing timestamps.
Inpatient discharge summary—ANSWER--Must include final diagnoses and outcome to meet
documentation standards.
Scanned faxes—ANSWER--Classified as secondary data once stored electronically.
EMR artifacts—ANSWER--Part of the electronic content management system
Unreviewable external documentation—ANSWER--Documentation that cannot be reviewed
for accuracy or compliance
Late entry—ANSWER--An entry made after the event has occurred, which must be clearly
identified
H&P—ANSWER--History and Physical, a document that records a patient's medical history
and physical examination findings
MAR—ANSWER--Medication Administration Record, a document that tracks medications
administered to a patient
© 2026 Copyright. All Rights Reserved. This document is
protected by copyright law, Copyrighted By Brittie Donald
