WGU C810 Questions Perfectly Solved And Graded A+

Which component of the patient portal is the ability to see a doctor's availability? Scheduling Where would information about the patient's insulin dosage be found within the portal? 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? 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? 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? 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? 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? 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? History and physical Which type of consent is a patient asked to sign prior to undergoing a scheduled gallbladder surgery? Informed consent Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg while hospitalized? Medication administration record (MAR) Which person's signature must be included on a consent form? 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? CMS-1500 Which guideline should an HIM professional use for documentation of both paper and electronic records? The original documents should be maintained in the health record Which type of information can be found in a physician's order? 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? 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? Uniform Hospital Discharge Data Set (UHDDS) Which data type is a cardiac catheterization examination note an example of? 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? Unstructured Structured or Unstructured data: A zip code is entered and the state is automatically populated. Structured Structured or Unstructured data: PT chooses Therapy tab in the EHR and writes their treatment plan notes. 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 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? 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? 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? 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? 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? 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? 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? 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? Availability Which term refers to the manner in which policy makers, data owners, data stewards, and other stakeholders interact with each other? Rules of engagement What does a stakeholder analysis of a data governance system identify? Needs of those interested in the data What is a best practice for data governance that should be incorporated into every program? Specifying data quality requirements Which organization requires cancer statistics to be reported from central registries to the national organization responsible for cancer statistics? 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? National Practitioner Data Bank (NPDB) Which organization administers voluntary accreditation programs and provides deemed status to certified hospitals and other healthcare organizations? The Joint Commission What is the CMS external audit program that works to reduce MCR improper payments? RACs Which assessment do the CoP require all home health agencies to electronically report? OASIS To which organization must a sentinel event be reported? The Joint Commission Which HIE architecture describes information that flows to more than one regional clinical data repository (CDR) and requested records sent from one regional authority? Federated Which HIE model supports uniformity of data, quick response times to queries, and consistency in data accessibility? Centralized A local SNF, hospital, and public health agency all participate in an HIE. The data is pushed from their facilities into one repository where they all have access to retrieve data when needed. Which HIE model is used in this scenario? Centralized Which characteristic addresses the level of depth represented by data in a fact or dimension table in a data warehouse? Granularity Which quality describes data that is unaffected when used across all applications and systems? Consistency An HIM analyst is charged with reviewing abstracted information on opiod-related admissions from the hospital's disease index database. The analyst wants to make sure that the correct ICD-10 codes have been abstracted and pulled from the database. Which data quality characteristic does this situation involve? Accuracy An HIM director is auditing physician documentation and finds that 3% of the discharge summaries from the last 6 months were completed more than 30 days past patient discharge. Which data quality standard is an area of concern in this scenario? Timeliness Once a year, members of the Disaster Planning Committee meet to conduct mock drills that satisfy staff training requirements as outlined in the organization's disaster plan. What is the best practice for training staff on disaster protocol? Arrange for continuous training through in-service programs and conducting mock drills In the event that a disaster affects a facility, how should damage to off-site records be prevented? Off-site storage should be located at a distance far enough away from the facility. Which security feature should be enabled on backup tapes as a best practice to prevent data breach? Encryption