WGU C810 questions with complete solution (TEST
BANK)///WGU C810 questions with complete
solution (TEST BANK)
- In regard to quality of coding, the degree to which the same results (same codes) are
obtained by different coders or on multiple attempts by the same coders refers to
A) Emergency record
B) Medical consultation
C) Pharmacy consultation
D) Physical exam
C) Pharmacy consultation - Determine which of the following is a form or view that is
typically seen in the health record of a long term care patient but is rarely seen in
records of acute care patients
A) The quality of follow up care
B) Whether a postoperative infection occurred and how it was treated
C) Whether the severity of illness and intensity of service warranted acute level care
D) The presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed
D) The presence or absence of such items as preoperative and postoperative
diagnosis, description of findings, and specimens removed - The health care providers
at your hospital do a very thorough job of periodic open record review to ensure the
completeness of record documentation. A qualitative review or surgical records would
likely include checking for documentation regarding:
A) UHDDS
B) Glossary of healthcare terms
C) MDS
D) Facility data dictionary
,D) Facility data dictionary - As the chair of a forms review committee, you need to track
the field name of a particular data field and the security levels applicable to that field.
Determine the best source for this information
A) Prohibited use of any abbreviations
B) Use of abbreviations in the final diagnosis
C) Flagrant use of specialty -specific abbreviations
D) Use of prohibited or dangerous abbreviations
D) Use of prohibited or dangerous abbreviations - In the past, Joint Commission
standards have focused on promoting the use of a facility-approved abbreviation list to
be used by hospital care providers. With the advent of the commission's national patient
safety goals, the focus has shifted to the
A) Legal review
B) Quantitative analysis
C) Qualitative analysis
D) Utilization review
C) Qualitative analysis
A) Implant
B) HIV/AIDS
C) Birth defects
D) Trauma
C) Birth defects - Case definition is important for all types of registries. Age will certainly
be an important criterion for accessing a case in a __________________ registry
A) Completeness
B) Consistency
C) Clarity
D) Precision
D) Precision - A coder came across a medical record where a sputum culture indicated
bacterial pneumonia but the diagnosis did not indicate the cause of the pneumonia.
Documentation in the patient's record failed to meet which one of the following criteria:
A) National Practitioner Data Bank
B) RxNorm
C) Vital statistics
,D) MEDPAR
D) MEDPAR - You need to analyze data on the types of care provided to Medicare
patients in your geographic area by DRG. Which of the following would be most helpful?
A) Validity
B) Timeliness
C) Reliability
D) Completeness
D) Completeness - The coding supervisor notices that the coders are routinely failing to
code all possible diagnoses and procedures for a patient encounter. This indicates to
the supervisor that there is a problem with
A) Aggregate data
B) MPI data
C) Protocol data
D) Patient - identifiable data
A) Aggregate data - You are looking at statistics for your facility that include average
length of stay and discharge data by DRG/ What type of data are you reviewing?
A) Timeliness
B) Completeness
C) Validity
D) Reliability
D) Reliability - During a retrospective review of Rose Hunter's inpatient health record,
the health information clerk notes that on day 4 of hospitalization, there was one missed
dose of insulin. Determine what type of review is this clerk performing?
A) Time and means of arrival
B) Instructions for follow up care
C) Physical findings
D) Lab/diagnostic results
A) Time and means of arrival - Determine the key data item you would expect to find
recorded on an ER record but would probably NOT see in an acute care record
, A) Security
B) Timeliness
C) Comprehensiveness
D) Accuracy
C) Comprehensiveness - Using a template to collect data for key reports may help to
prompt caregivers to document all required data elements in the patient record. This
practice contributes to data
A) Condition on discharge
B) Chief complaint
C) Time and means of arrival
D) APGAR score
D) APGAR score - Determine the data item to include on a qualitative review checklist
of newborn inpatient health records that need NOT to be included on adult records
A) Compliance with Medicare regulations
B) Compliance with Joint Commission standards
C) Compliance with Joint Commission standards for nonsurgical patients
D) Noncompliance with Joint Commission standards
D) Noncompliance with Joint Commission standards - A qualitative review of a health
record reveals that the history and physical for a patient
admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the
following statements regarding the history and physical is true in this situation?
Completion and charting of the H&P indicates
A) Problem list
B) Patient's condition on discharge
C) Advance directive
D) Time and means of arrival
B) Patient's condition on discharge - One record documentation requirement shared by
both acute care and emergency departments is
A) Missing discharge summaries
B) Missing signatures on progress notes
C) Absence of SOAP format in progress notes
D) Missing operative reports
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