FOUNDATIONS IN HEALTHCARE DATA MANAGEMENT EXAM QUESTIONS SOLVED 100% LATEST
VERSION 2025
A physician group is updating its electronic database system to allow patients to create profiles and
provide access to necessary individuals. Patients have the opportunity to access their personal health
information electronically from remote locations. The patients like being able to see the doctor's open
times to coordinate their schedules before requesting an office visit.Which component of the patient
portal is the ability to see a doctor's availability? - Answers Scheduling
A patient is admitted to an acute care facility while on vacation, but records from his physician's office
cannot be immediately obtained. The patient has difficulty remembering his insulin dosage, but he
recalls being enrolled in a patient portal.Where would information about the patient's insulin dosage be
found within this portal? - Answers Medication history
Which form of review is conducted after a patient is discharged from an acute care facility in order 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 health records. The records are
filed according to a three-part number made up of two-digit pairs. Which type of system is this? -
Answers Terminal-digit filing system
A patient goes to an emergency room complaining of chest pain and is released home four hours
later.Which type of documentation is required in this scenario? - Answers Discharge orders
A physician in an acute care facility is performing an H&P in accordance with the CMS Conditions of
Participation.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 do the Centers for Medicare and Medicaid Services (CMS)
Conditions of Participation 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 before 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
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 Medicare, but the system is
experiencing an outage.Which form should this doctor use to submit a paper claim? - Answers CMS-
1500
Which guideline should an health information management (HIM) professional follow for
documentation of both paper and electronic records? - Answers Original documents should be
maintained in the health record.
In which time frame should the history and physical be completed after a patient is admitted to an
inpatient healthcare facility? - Answers No more than 30 days before or 24 hours after admission
Which type of information can be found in a physician's orders? - 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 a patient's medical
record.What must the record include to meet Centers for Medicare and Medicaid Services (CMS)
requirements? - Answers Minimum Data Set (MDS)
A state hospital system is collecting information on inpatient discharges from hospitals in the central
part of a state.Which database 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
A nurse enters a patient's zip code, and the state is automatically populated. - Answers Structured data
A physical therapist chooses the Therapy tab in the emergency health record and writes treatment plan
notes. - Answers Unstructured data
A nurse answers a question on an assessment screen in the emergency health record by clicking a radio
button in front of a Yes or a No. - Answers Structured data
A nurse adds a description of a patient's problem to the clinical assessment field. - Answers
Unstructured data
A physician adds a picture of a patient's wound to the patient's emergency health record. - Answers
Unstructured data
A health information management (HIM) director and a chief information officer have been asked to
update the data governance strategic plan for their healthcare system. In particular, they are working on
standardizing data governance language across the healthcare system and ensuring that they meet data
VERSION 2025
A physician group is updating its electronic database system to allow patients to create profiles and
provide access to necessary individuals. Patients have the opportunity to access their personal health
information electronically from remote locations. The patients like being able to see the doctor's open
times to coordinate their schedules before requesting an office visit.Which component of the patient
portal is the ability to see a doctor's availability? - Answers Scheduling
A patient is admitted to an acute care facility while on vacation, but records from his physician's office
cannot be immediately obtained. The patient has difficulty remembering his insulin dosage, but he
recalls being enrolled in a patient portal.Where would information about the patient's insulin dosage be
found within this portal? - Answers Medication history
Which form of review is conducted after a patient is discharged from an acute care facility in order 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 health records. The records are
filed according to a three-part number made up of two-digit pairs. Which type of system is this? -
Answers Terminal-digit filing system
A patient goes to an emergency room complaining of chest pain and is released home four hours
later.Which type of documentation is required in this scenario? - Answers Discharge orders
A physician in an acute care facility is performing an H&P in accordance with the CMS Conditions of
Participation.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 do the Centers for Medicare and Medicaid Services (CMS)
Conditions of Participation 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 before 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
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 Medicare, but the system is
experiencing an outage.Which form should this doctor use to submit a paper claim? - Answers CMS-
1500
Which guideline should an health information management (HIM) professional follow for
documentation of both paper and electronic records? - Answers Original documents should be
maintained in the health record.
In which time frame should the history and physical be completed after a patient is admitted to an
inpatient healthcare facility? - Answers No more than 30 days before or 24 hours after admission
Which type of information can be found in a physician's orders? - 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 a patient's medical
record.What must the record include to meet Centers for Medicare and Medicaid Services (CMS)
requirements? - Answers Minimum Data Set (MDS)
A state hospital system is collecting information on inpatient discharges from hospitals in the central
part of a state.Which database 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
A nurse enters a patient's zip code, and the state is automatically populated. - Answers Structured data
A physical therapist chooses the Therapy tab in the emergency health record and writes treatment plan
notes. - Answers Unstructured data
A nurse answers a question on an assessment screen in the emergency health record by clicking a radio
button in front of a Yes or a No. - Answers Structured data
A nurse adds a description of a patient's problem to the clinical assessment field. - Answers
Unstructured data
A physician adds a picture of a patient's wound to the patient's emergency health record. - Answers
Unstructured data
A health information management (HIM) director and a chief information officer have been asked to
update the data governance strategic plan for their healthcare system. In particular, they are working on
standardizing data governance language across the healthcare system and ensuring that they meet data
