C810 - Health records, Content, and Documentation 2023/2024 already passed

C810 - Health records, Content, and DocumentationScheduling - correct answer 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 electronic life long resource of health information from remote locations. The patients like being able to see the doctor's open times to coordinate their personal schedules before requesting an office visit. Which component of the patient portal is the ability to see a doctor's availability? Medication History - correct answer A patient was 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? Closed Record Review - correct answer 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? Terminal-digit filing system - correct answer 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? Discharge Orders - correct answer 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? 30 days; 24 hours - correct answer A physician in an acute care facility is performing a H&P in accordance with CMS Conditions and 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? A physician should issue the order in writing. - correct answer 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? History and Physical - correct answer 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? Informed Consent - correct answer Which type of consent is a patient asked to sign prior to undergoing a scheduled gallbladder surgery? Medication administration record (MAR) - correct answer Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg while hospitalized? Patient - correct answer Which person's signature must be included on a consent form? CMS-1500 - correct answer In a physician's practice, a doctor is attempting to submit a claim to Medicare, but the system is experiencing an outage. Which form would this doctor use to submit a paper claim The original documents should be maintained in the health record. - correct answer Which guideline should an HIM professional use for documentation of both paper and electronic records?