Foundations in Healthcare Data
Management - C810 UPDATED ACTUAL
Exam Questions and CORRECT Answers
Do-Not-Resuscitate order (DNR) - CORRECT ANSWER - Specifies an individual's wish
not to receive treatment (specifically, cardiopulmonary resuscitation or CPR), directing
healthcare providers to refrain from performing the otherwise standing order of CPR should the
individual experience cardiac or respiratory arrest, and is most often used by the elderly or
chronically ill
Advanced Directives - CORRECT ANSWER - A special type of written consent that
communicates an individual's wishes to be treated or not to be treated should the individual
become incapacitated and unable to communicate on his or her own behalf
Incident report - CORRECT ANSWER - A tool staff can use to report unusual incidents to
administration.
Depending on the state, an incident report may or may not be protected by statute or regulation.
It may also be protected per attorney-client privilege. However, this protection can be superseded
if the court determines the information is necessary to a plaintiff's case. Although the facts
regarding the incident and the resolution should be documented in the clinical record, the
incident report itself is not part of the health record and should never be placed in the record nor
referred to in the record.
Informed consent - CORRECT ANSWER - 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 (to include opting out of treatment); and individuals who will perform the
treatment or procedure
Metadata - CORRECT ANSWER - Electronic data about data that include information not
previously available in paper documents, such as time stamps that show when and by whom a
document or entry was created, accessed, or changed
,Consultation - CORRECT ANSWER - the act of seeking assistance from another
physician(s) or health care professional(s) for diagnostic studies, therapeutic interventions, or
other services that may benefit the patient. opinions of physicians with specialty training beyond
general board certification such as oncologists, cardiologists, or dermatologists.
Discharge summary - CORRECT ANSWER - Also called the clinical resume, provides
details about the patient's stay while in the facility, is the foundation for future treatment, and is
prepared when the patient is discharged or transferred to another facility or when the patient dies
Durable power of attorney - CORRECT ANSWER - A document in which an adult—while
competent—designates another person (proxy) to make healthcare decisions consistent with the
individual's wishes on the individual's behalf if he or she is unable
History and Physical - includes history of present illness and review of systems - CORRECT
ANSWER - The history and physical form includes both information about what has led
up to the current medical issue and the practitioner's investigation into what the problem actually
is. The history is a summary of the patient's illness from his or her point of view. Its purpose is to
allow the patient or his or her authorized representative to give the practitioner as much
background information about the patient's illness as possible.
The physical examination is a comprehensive assessment of the patient's physical condition
through examination and inspection of the patient's body by the practitioner. The practitioner
usually tailors the physical examination to symptoms described in the patient's history and begins
an assessment. The end of the physical examination should include the impression, which is a list
of the patient's problems based on the information obtained
Hybrid record - CORRECT ANSWER - A patient health record that exists in a paper-based
and an electronic format
Joint Commission - CORRECT ANSWER - The successor organization to the American
College of Surgeons (ACS) in the area of standardization that assumed responsibility for the
accreditation process in 1952 as a joint effort of the ACS, American College of Physicians,
American Medical Association, and the American Hospital Association; was initially responsible
for the accreditation of hospitals and has since expanded its accreditation process to home health,
long-term care, and other types of healthcare facilities
, Master Patient Index (MPI) - CORRECT ANSWER - A permanent database including
patient-identifiable data for every patient ever admitted to or treated by the facility
Medication Administration Record (MAR) - CORRECT ANSWER - A record that is
maintained by nursing staff for all patients and includes medications given, time, form of
administration, and dosage and strength
Patient/member web portal - CORRECT ANSWER - A web-based tool or a personal
health record offered by the patient's healthcare provider that allows patients to pay their bills
online and to securely view all or portions of their provider-based EHR, such as current medical
conditions, immunization records, medications, allergies, and test results
Personal health record (PHR) - CORRECT ANSWER - Tools that individuals can use to
collect, track, and share past and current information about their health or the health of someone
in their care
Problem-oriented medical record - CORRECT ANSWER - Developed in the 1970s and is
comprised of the problem list, the database (the history and physical examination and initial lab
findings), the initial plan (tests, procedures, and other treatments), and progress notes organized
so that every member of the healthcare team can easily follow the course of patient treatment
Progress notes - includes care, treatment and therapies - CORRECT ANSWER -
chronological statements about the patient's response to treatment during his or her stay in the
facility. Facility procedures and policies must state exactly what categories of personnel are
allowed to write or enter information into progress notes. Generally, these personnel include
physicians, nurses, physical therapists, occupational therapists, respiratory therapists, social
workers, case managers, registered dietitians (RDs), nurse anesthetists, pharmacists, radiologic
technologists, speech therapists, and others providing direct treatment or consultation to the
patient
Record retention - CORRECT ANSWER - Involves determining the schedule to be
followed to protect and preserve active and inactive records
Management - C810 UPDATED ACTUAL
Exam Questions and CORRECT Answers
Do-Not-Resuscitate order (DNR) - CORRECT ANSWER - Specifies an individual's wish
not to receive treatment (specifically, cardiopulmonary resuscitation or CPR), directing
healthcare providers to refrain from performing the otherwise standing order of CPR should the
individual experience cardiac or respiratory arrest, and is most often used by the elderly or
chronically ill
Advanced Directives - CORRECT ANSWER - A special type of written consent that
communicates an individual's wishes to be treated or not to be treated should the individual
become incapacitated and unable to communicate on his or her own behalf
Incident report - CORRECT ANSWER - A tool staff can use to report unusual incidents to
administration.
Depending on the state, an incident report may or may not be protected by statute or regulation.
It may also be protected per attorney-client privilege. However, this protection can be superseded
if the court determines the information is necessary to a plaintiff's case. Although the facts
regarding the incident and the resolution should be documented in the clinical record, the
incident report itself is not part of the health record and should never be placed in the record nor
referred to in the record.
Informed consent - CORRECT ANSWER - 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 (to include opting out of treatment); and individuals who will perform the
treatment or procedure
Metadata - CORRECT ANSWER - Electronic data about data that include information not
previously available in paper documents, such as time stamps that show when and by whom a
document or entry was created, accessed, or changed
,Consultation - CORRECT ANSWER - the act of seeking assistance from another
physician(s) or health care professional(s) for diagnostic studies, therapeutic interventions, or
other services that may benefit the patient. opinions of physicians with specialty training beyond
general board certification such as oncologists, cardiologists, or dermatologists.
Discharge summary - CORRECT ANSWER - Also called the clinical resume, provides
details about the patient's stay while in the facility, is the foundation for future treatment, and is
prepared when the patient is discharged or transferred to another facility or when the patient dies
Durable power of attorney - CORRECT ANSWER - A document in which an adult—while
competent—designates another person (proxy) to make healthcare decisions consistent with the
individual's wishes on the individual's behalf if he or she is unable
History and Physical - includes history of present illness and review of systems - CORRECT
ANSWER - The history and physical form includes both information about what has led
up to the current medical issue and the practitioner's investigation into what the problem actually
is. The history is a summary of the patient's illness from his or her point of view. Its purpose is to
allow the patient or his or her authorized representative to give the practitioner as much
background information about the patient's illness as possible.
The physical examination is a comprehensive assessment of the patient's physical condition
through examination and inspection of the patient's body by the practitioner. The practitioner
usually tailors the physical examination to symptoms described in the patient's history and begins
an assessment. The end of the physical examination should include the impression, which is a list
of the patient's problems based on the information obtained
Hybrid record - CORRECT ANSWER - A patient health record that exists in a paper-based
and an electronic format
Joint Commission - CORRECT ANSWER - The successor organization to the American
College of Surgeons (ACS) in the area of standardization that assumed responsibility for the
accreditation process in 1952 as a joint effort of the ACS, American College of Physicians,
American Medical Association, and the American Hospital Association; was initially responsible
for the accreditation of hospitals and has since expanded its accreditation process to home health,
long-term care, and other types of healthcare facilities
, Master Patient Index (MPI) - CORRECT ANSWER - A permanent database including
patient-identifiable data for every patient ever admitted to or treated by the facility
Medication Administration Record (MAR) - CORRECT ANSWER - A record that is
maintained by nursing staff for all patients and includes medications given, time, form of
administration, and dosage and strength
Patient/member web portal - CORRECT ANSWER - A web-based tool or a personal
health record offered by the patient's healthcare provider that allows patients to pay their bills
online and to securely view all or portions of their provider-based EHR, such as current medical
conditions, immunization records, medications, allergies, and test results
Personal health record (PHR) - CORRECT ANSWER - Tools that individuals can use to
collect, track, and share past and current information about their health or the health of someone
in their care
Problem-oriented medical record - CORRECT ANSWER - Developed in the 1970s and is
comprised of the problem list, the database (the history and physical examination and initial lab
findings), the initial plan (tests, procedures, and other treatments), and progress notes organized
so that every member of the healthcare team can easily follow the course of patient treatment
Progress notes - includes care, treatment and therapies - CORRECT ANSWER -
chronological statements about the patient's response to treatment during his or her stay in the
facility. Facility procedures and policies must state exactly what categories of personnel are
allowed to write or enter information into progress notes. Generally, these personnel include
physicians, nurses, physical therapists, occupational therapists, respiratory therapists, social
workers, case managers, registered dietitians (RDs), nurse anesthetists, pharmacists, radiologic
technologists, speech therapists, and others providing direct treatment or consultation to the
patient
Record retention - CORRECT ANSWER - Involves determining the schedule to be
followed to protect and preserve active and inactive records
