C810 questions with 100% correct answers graded A+ 2023/2024

C810Which component of the patient portal is the ability to see a doctor's availability? - correct answer Scheduling Where would information about the patient's insulin dosage be found within the portal? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer 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? - correct answer History and physical Which type of consent is a patient asked to sign prior to undergoing a scheduled gallbladder surgery? - correct answer Informed consent Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg while hospitalized? - correct answer Medication administration record (MAR) Which person's signature must be included on a consent form? - correct answer 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? - correct answer CMS-1500 Which guideline should an HIM professional use for documentation of both paper and electronic records? - correct answer The original documents should be maintained in the health record Which type of information can be found in a physician's order? - correct answer 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? - correct answer 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? - correct answer Uniform Hospital Discharge Data Set (UHDDS) Which data type is a cardiac catheterization examination note an example of? - correct answer Unstructured data