WGU C810 Health Records & Documentation (1)

Which record review process is ongoing while a patient is in a healthcare facility to ensure that documentation requirements are met? | A. Qualitative analysis | B. Quantitative analysis | C. An open-record review | D. Closed-record review

C. An open-record review

Which healthcare setting requires specific documentation by the attending physician and updates to the patient's plan of care according to CMS? | A. Outpatient care | B. Behavioral healthcare | C. Rehabilitation services | D. Home healthcare

D. Home healthcare

Which document provides the exact details of the treatment and must be signed by the patient or legal representative? | A. Durable power of attorney | B. Advance directives | C. Informed consent | D. Living will

C. Informed consent

Which technology could assist a patient in accessing their bill and making payments online? | A. CPOE | B. Telehealth | C. Patient/member web portal | D. Patient-generated health data

C. Patient/member web portal

For which healthcare settings is the patient's history and physical examination a required part of the health record? | A. Acute care and long-term care | B. Acute care and home healthcare | C. Acute care and behavioral health | D. Emergency and acute care

C. Acute care and behavioral health

A qualitative review of surgical records would most likely include which information? | A. Plan of care and follow-up care documentation | B. Documentation of preoperative infections and treatments | C. Severity of illness and intensity of services | D. Preoperative and postoperative diagnoses, findings, and specimens removed

D. Preoperative and postoperative diagnoses, findings, and specimens removed

Which section of a patient portal should a patient access to review information shared during a recent office visit? | A. Medical history | B. Visit summaries | C. Document center | D. Upcoming appointments

B. Visit summaries

Before an elective surgical procedure in an ambulatory surgery center, which documentation must be present? | A. Advance directive | B. Name of the surgeon and procedure | C. Pertinent laboratory results | D. Recent history and physical

D. Recent history and physical

A report containing evidence of record review, examination findings, and recommendations is called what? | A. History and physical | B. Consultation report | C. Operative report | D. Admission note

B. Consultation report

Why is the operative report used during an inpatient hospitalization? | A. To summarize care provided | B. To document surgical findings | C. To communicate the initial plan of care | D. To communicate the current condition

B. To document surgical findings

Which data standard is used for reporting inpatient operative procedures? | A. ICD-10-CM | B. ICD | C. ICD-O | D. ICD-10-PCS

D. ICD-10-PCS

Which documentation are ambulatory care providers more likely than acute care providers to rely upon for continuity of care? | A. Transfer record | B. Interdisciplinary patient care plan | C. Problem list | D. Intake summary

C. Problem list

What is the best definition of a care path? | A. A record containing transportation information | B. Observations of the patient's response to treatment | C. Protocol for the process of care | D. A statement of the patient's wishes

C. Protocol for the process of care

Which type of health record has created new challenges for HIM professionals because patients interact directly with it? | A. Telehealth records | B. Emergency health records | C. Electronic health records | D. Electronic personal health records (PHRs)

D. Electronic personal health records (PHRs)

Which documentation is acceptable in an emergency when the formal report has been dictated but not yet transcribed? | A. Patient history | B. Physician orders | C. Consultation note | D. Preoperative note

D. Preoperative note

Which healthcare technology is critical for patient engagement and supports long-distance clinical care and health-related education? | A. EHRs | B. Telehealth | C. Patient portals | D. Computerized provider order entry

B. Telehealth

Which form of connectivity provides patients secure access to their most recent laboratory results? | A. Telemedicine | B. Electronic health records | C. Personal health records | D. Patient portals

D. Patient portals

Who is ultimately responsible for ensuring the quality of entries made in the health record? | A. HIM department | B. Medical staff committee | C. Care provider | D. Quality improvement department

C. Care provider

Quantitative analysis is a review of the record for which purpose? | A. Medical necessity | B. Quality of documentation | C. Completeness and accuracy | D. Severity of illness

C. Completeness and accuracy

Qualitative analysis primarily reviews which aspect of the record? | A. Presence of signatures | B. Filing order | C. Quality and accuracy of documentation | D. Number of reports present

C. Quality and accuracy of documentation

As health records move to electronic formats, which principle remains important in form and template design? | A. Provider autonomy | B. Forms control | C. Increased clicks | D. Decentralization

B. Forms control

Which index serves as the key locator for records in a numerical filing system? | A. Disease index | B. Operation index | C. Master patient index | D. Physician index

C. Master patient index

Which problem occurs when one patient's record is overwritten with information from another patient? | A. Duplicate | B. Overlap | C. Overlay | D. Merge

C. Overlay

Which problem occurs when a patient has more than one medical record number assigned across more than one database? | A. Overlay | B. Overlap | C. Duplicate provider record | D. Misfiling

B. Overlap

What numbering system assigns a different number for each episode of care and brings forward information under the last number issued? | A. Unit numbering system | B. Serial numbering system | C. Serial-unit numbering system | D. Terminal digit numbering

C. Serial-unit numbering system

Which record review process is ongoing while a patient is in a healthcare facility to ensure that documentation requirements are met? | A. Qualitative analysis | B. Quantitative analysis | C. An open-record review | D. Closed-record review

C. An open-record review

Which healthcare setting requires specific documentation by the attending physician and updates to the patient's plan of care according to CMS? | A. Outpatient care | B. Behavioral healthcare | C. Rehabilitation services | D. Home healthcare

D. Home healthcare

Which document provides the exact details of the treatment and must be signed by the patient or legal representative? | A. Durable power of attorney | B. Advance directives | C. Informed consent | D. Living will

C. Informed consent

Which technology could assist a patient in accessing their bill and making payments online? | A. CPOE | B. Telehealth | C. Patient/member web portal | D. Patient-generated health data

C. Patient/member web portal

For which healthcare settings is the patient's history and physical examination a required part of the health record? | A. Acute care and long-term care | B. Acute care and home healthcare | C. Acute care and behavioral health | D. Emergency and acute care

C. Acute care and behavioral health

A qualitative review of surgical records would most likely include which information? | A. Plan of care and follow-up care documentation | B. Documentation of preoperative infections and treatments | C. Severity of illness and intensity of services | D. Preoperative and postoperative diagnoses, findings, and specimens removed

D. Preoperative and postoperative diagnoses, findings, and specimens removed

Which section of a patient portal should a patient access to review information shared during a recent office visit? | A. Medical history | B. Visit summaries | C. Document center | D. Upcoming appointments

B. Visit summaries

Before an elective surgical procedure in an ambulatory surgery center, which documentation must be present? | A. Advance directive | B. Name of the surgeon and procedure | C. Pertinent laboratory results | D. Recent history and physical

D. Recent history and physical

A report containing evidence of record review, examination findings, and recommendations is called what? | A. History and physical | B. Consultation report | C. Operative report | D. Admission note

B. Consultation report

Why is the operative report used during an inpatient hospitalization? | A. To summarize care provided | B. To document surgical findings | C. To communicate the initial plan of care | D. To communicate the current condition

B. To document surgical findings

Which data standard is used for reporting inpatient operative procedures? | A. ICD-10-CM | B. ICD | C. ICD-O | D. ICD-10-PCS

D. ICD-10-PCS

Which documentation are ambulatory care providers more likely than acute care providers to rely upon for continuity of care? | A. Transfer record | B. Interdisciplinary patient care plan | C. Problem list | D. Intake summary

C. Problem list

What is the best definition of a care path? | A. A record containing transportation information | B. Observations of the patient's response to treatment | C. Protocol for the process of care | D. A statement of the patient's wishes

C. Protocol for the process of care

Which type of health record has created new challenges for HIM professionals because patients interact directly with it? | A. Telehealth records | B. Emergency health records | C. Electronic health records | D. Electronic personal health records (PHRs)

D. Electronic personal health records (PHRs)

Which documentation is acceptable in an emergency when the formal report has been dictated but not yet transcribed? | A. Patient history | B. Physician orders | C. Consultation note | D. Preoperative note

D. Preoperative note

Which healthcare technology is critical for patient engagement and supports long-distance clinical care and health-related education? | A. EHRs | B. Telehealth | C. Patient portals | D. Computerized provider order entry

B. Telehealth

Which form of connectivity provides patients secure access to their most recent laboratory results? | A. Telemedicine | B. Electronic health records | C. Personal health records | D. Patient portals

D. Patient portals

Who is ultimately responsible for ensuring the quality of entries made in the health record? | A. HIM department | B. Medical staff committee | C. Care provider | D. Quality improvement department

C. Care provider

Quantitative analysis is a review of the record for which purpose? | A. Medical necessity | B. Quality of documentation | C. Completeness and accuracy | D. Severity of illness

C. Completeness and accuracy

Qualitative analysis primarily reviews which aspect of the record? | A. Presence of signatures | B. Filing order | C. Quality and accuracy of documentation | D. Number of reports present

C. Quality and accuracy of documentation

As health records move to electronic formats, which principle remains important in form and template design? | A. Provider autonomy | B. Forms control | C. Increased clicks | D. Decentralization

B. Forms control

Which index serves as the key locator for records in a numerical filing system? | A. Disease index | B. Operation index | C. Master patient index | D. Physician index

C. Master patient index

Which problem occurs when one patient's record is overwritten with information from another patient? | A. Duplicate | B. Overlap | C. Overlay | D. Merge

C. Overlay

Which problem occurs when a patient has more than one medical record number assigned across more than one database? | A. Overlay | B. Overlap | C. Duplicate provider record | D. Misfiling

B. Overlap

What numbering system assigns a different number for each episode of care and brings forward information under the last number issued? | A. Unit numbering system | B. Serial numbering system | C. Serial-unit numbering system | D. Terminal digit numbering

C. Serial-unit numbering system

What numbering system assigns one number to a patient on the first encounter and retains that number for all subsequent visits? | A. Serial numbering system | B. Serial-unit numbering system | C. Unit numbering system | D. Terminal digit numbering

C. Unit numbering system

When retention requirements vary among state law, CMS regulations, and accreditation standards, which requirement should be followed? | A. Facility policy | B. Federal regulations | C. State law | D. The strictest requirement

D. The strictest requirement

What are the four primary steps in an effective record retention program? | A. Inventory, storage format and location, assigning retention periods, destruction | B. Scanning, indexing, archiving, destruction | C. Filing, retrieving, reviewing, destruction | D. Inventory, coding, storage, destruction

A. Inventory, storage format and location, assigning retention periods, destruction

Privacy refers to which concept? | A. Protection of information from unauthorized access | B. The right of an individual to be left alone | C. Authentication of information | D. Information ownership

B. The right of an individual to be left alone

Confidentiality refers to which concept? | A. Maintaining privacy and security | B. Restricting unauthorized disclosure of information | C. Information ownership | D. Data retention

B. Restricting unauthorized disclosure of information

Security refers to which concept? | A. The patient's right to privacy | B. Restricting disclosures | C. Maintaining privacy and confidentiality | D. Information ownership

C. Maintaining privacy and confidentiality

Before releasing records to an attorney for a malpractice case, which documentation is required? | A. Court order | B. Verbal authorization | C. Signed authorization for disclosure of PHI | D. Progress note

C. Signed authorization for disclosure of PHI

Which advance directive designates another person to make healthcare decisions on behalf of a patient? | A. Living will | B. DNR | C. Durable power of attorney for healthcare | D. Informed consent

C. Durable power of attorney for healthcare

Which advance directive addresses extraordinary lifesaving measures such as ventilator support and nutrition? | A. DNR | B. Living will | C. Guardianship | D. Informed consent

B. Living will

Which advance directive expresses an individual's wish not to receive cardiopulmonary resuscitation? | A. Living will | B. Durable power of attorney | C. DNR | D. Guardianship

C. DNR

Why should providers follow the approval process when requesting a new form? | A. To improve reimbursement | B. To maintain control and avoid duplication | C. To reduce signatures | D. To eliminate templates

B. To maintain control and avoid duplication

How do templates and forms improve data quality? | A. By reducing retention requirements | B. By improving reliability and consistency of documentation | C. By replacing authentication requirements | D. By eliminating paper records

B. By improving reliability and consistency of documentation

What is one reason incorrect patient information may appear in the record? | A. Standardized terminology | B. Different names or initials being used for the same patient | C. Data dictionaries | D. Structured data

B. Different names or initials being used for the same patient

Which common attributes are used to correctly identify patients? | A. Diagnosis and DRG | B. Full name, date of birth, address, gender, and medical record number | C. Insurance company and room number | D. Billing amount and physician specialty

B. Full name, date of birth, address, gender, and medical record number

Why is maintaining an accurate MPI critical? | A. To improve coding productivity | B. To support quality and safety of patient care | C. To reduce insurance claims | D. To increase census counts

B. To support quality and safety of patient care

Duplicate records can negatively affect providers during medical malpractice litigation because they may create discrepancies involving what? | A. Staffing levels | B. Diagnoses, medications, and allergies | C. Billing records | D. Room assignments

B. Diagnoses, medications, and allergies

Who establishes the rules and regulations for record content? | A. HIM department | B. Medical staff bylaws | C. Risk management department | D. Coding department

B. Medical staff bylaws

Which professional often reports incomplete and delinquent records during committee meetings? | A. Case manager | B. Utilization review nurse | C. HIM director | D. Coding supervisor

C. HIM director

When defining the legal health record, organizations should consider which sources? | A. Federal Rules of Evidence and state and federal laws | B. Coding guidelines only | C. Medicare reimbursement manuals | D. Physician preference

A. Federal Rules of Evidence and state and federal laws

What tool identifies all locations where health information may reside? | A. Disease index | B. Source system matrix | C. Data dictionary | D. MPI

B. Source system matrix

Which of the following may be included in a source system matrix? | A. Radiology images | B. Emails and text messages | C. Metadata | D. All of the above

D. All of the above

What is the purpose of a source system matrix? | A. To track physician privileges | B. To identify paper and electronic sources of health information | C. To assign medical record numbers | D. To organize coding systems

B. To identify paper and electronic sources of health information

What challenge do duplicate records create during litigation? | A. Increased coding accuracy | B. Difficulty presenting a case due to conflicting information | C. Faster discovery process | D. Reduced malpractice claims

B. Difficulty presenting a case due to conflicting information

What is the goal of maintaining a correct and current master patient index? | A. To create a truly longitudinal record from birth to death | B. To improve billing speed | C. To increase admissions | D. To reduce transcription costs

A. To create a truly longitudinal record from birth to death

Which problem occurs when one patient's record is overwritten with another patient's information? | A. Duplicate record | B. Overlay | C. Overlap | D. Merge

B. Overlay