WGU C810 (Actual) Exam Graded A+ 2023
Which component of the patient portal is the ability to see a doctor's availability? - ANSWER-Scheduling
Where would information about the patient's insulin dosage be found within the portal? - ANSWER-Medication history
Which form of review is conduc...
WGU C810 (Actual) Exam Graded A+ 2023
Which component of the patient portal is the ability to see a doctor's availability? -
ANSWER-Scheduling
Where would information about the patient's insulin dosage be found within the portal? -
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? -
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? - 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? -
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? -
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? - 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? - ANSWER-History and physical
Which type of consent is a patient asked to sign prior to undergoing a scheduled
gallbladder surgery? - ANSWER-Informed consent
Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg
while hospitalized? - ANSWER-Medication administration record (MAR)
Which person's signature must be included on a consent form? - 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? - ANSWER-CMS-1500
,Which guideline should an HIM professional use for documentation of both paper and
electronic records? - ANSWER-The original documents should be maintained in the
health record
Which type of information can be found in a physician's order? - 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?
- 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? - ANSWER-Uniform Hospital Discharge Data Set (UHDDS)
Which data type is a cardiac catheterization examination note an example of? -
ANSWER-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? - ANSWER-Unstructured
Structured or Unstructured data: A zip code is entered and the state is automatically
populated. - ANSWER-Structured
Structured or Unstructured data: PT chooses Therapy tab in the EHR and writes their
treatment plan notes. - ANSWER-Structured
Structured or Unstructured data: Nurse answers a question on an assessment screen in
the EHR by clicking a radial button in front of a Yes or a No - ANSWER-Structured
The HIM director and the CIO have been asked to update the healthcare system's data
governance strategic plan. In particular, they are working on standardizing data
governance language across the healthcare system and ensuring that they meed data
regulations and mandates. Which information governance principle is described in this
scenario? - ANSWER-Compliance
A hospital is informing the Infection Control Committee about the number of
postoperative infections it had during a given time period. Which principle for
governance is used in this scenario? - ANSWER-Transparency
A health information manager is responsible for properly destroying records after the
retention period has passed. Which principle for information governance is described in
this scenario? - ANSWER-Disposition
A communication plan is being developed to reduce mistrust and miscommunication in
a healthcare setting. In addition to open communication, which other principle for
, information governance must be considered when developing this plan? - ANSWER-
Transparency
A data governance steering committee is formed and tasked with developing the goals
of the data governance program. Which generally accepted record-keeping principle is
described in the scenario? - ANSWER-Accountability
A HIM director has been informed of potential data security violations. The HIM director
asks one of the health informatics analysts to work with the CIO to monitor the audit
trails of the EHR to identify any violations. Which generally accepted record-keeping
principle is described in this scenario? - ANSWER-Protection
The CIO is working to improve data security methodologies within the EHR. The CIO
enlists the help of the HIM director to help design and enforce the new data security
policies, which include the utilization of a new token system to access the EHR. Which
information governance principle is described in this scenario? - ANSWER-Protection
In a healthcare facility that still uses paper records, a physician is requesting a record to
complete a discharge summary that is now 28 days past due. The record tracker states
that the record has been sent to storage. Which record keeping principle would apply to
this scenario? - ANSWER-Availability
Which term refers to the manner in which policy makers, data owners, data stewards,
and other stakeholders interact with each other? - ANSWER-Rules of engagement
What does a stakeholder analysis of a data governance system identify? - ANSWER-
Needs of those interested in the data
What is a best practice for data governance that should be incorporated into every
program? - ANSWER-Specifying data quality requirements
Which organization requires cancer statistics to be reported from central registries to the
national organization responsible for cancer statistics? - ANSWER-Centers for Disease
Control and Prevention (CDC)
Which organization requires reporting of medical malpractice payments, federal
licensure and certification actions, and adverse clinical privileges actions? - ANSWER-
National Practitioner Data Bank (NPDB)
Which organization administers voluntary accreditation programs and provides deemed
status to certified hospitals and other healthcare organizations? - ANSWER-The Joint
Commission
What is the CMS external audit program that works to reduce MCR improper
payments? - ANSWER-RACs
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