HIT Chapter 3 check your understandings – Flashcards
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Which 2 major types of data are contained in the health record?
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Administrative & clinical
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Which of the following terms refers to state or county regulations that healthcare facilities must meet to be permitted to provide care?
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Licensure
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Which of the following would NOT be found in a medical history?
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Vital signs
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An attending physician requests the advice of a second physician who then reviews the health record & examines the patient. The second physician records impressions in what type of report?
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Consultation
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Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
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Care plan
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Written or spoken permission to proceed with care is calssified as?
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Expressed consent
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Which of the following reports provides information on tissue remove during a procedure?
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Pathology report
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Sleeping patterns, head & chest measurements, feeding & elimination status, weight, and Apgar scores are recorded in which of following records?
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newborn
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Which of the following is not considered patient demographic information?
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Admitting diagnosis
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Which of the following administrative documents names the patients choice of legal representative for healthcare purposes?
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Advance directive
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Which type of health record contains information about care provided prior to arrival at a healthcare setting & documentation of care provided to stabilize the patient?
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Emergency care
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Patient history questionnaires, problem lists, diagnostic test results, & immunization records are commonly found in which type of record?
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Ambulatory care
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The ambulatory surgery record contains information most similar to?
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Hospital operative records
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Which standardized tool is used to assess Medicare-certified rehab facilities?
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Patietn assessment instrument (PAI)
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Interdisciplinary care plan are an important part of which type of health record?
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Hospice care
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Portions of a treatment record may be maintained in a patients home in which 2 types of settings?
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Home health & end-stage renal disease
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A patients legal status, complaints of others regarding the patient, & reports of restraints or seclusion would be found most frequently in which type of health record?
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Behavioral health
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Paper records may require thinning in which 2 settings?
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Long-term care & correctional services
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A growth & development record may be found in what type of record?
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Pediatric
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The document that indicates current & past medical conditons is?
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Problem list
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Which of the following is an accrediting organization?
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DNV
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An accrediting organizaiton is awarded deemed status by Medicare. This means that facilities receiving accreditaiton under its guidelines do not need to?
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Undergo Medicare certification surveys
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Which group focuses on accreditation of managed care & preferred provider organizations?
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National Committee for Quality Assurance
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Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patients record?
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Facility rules & regulations
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Which of the following groups has instituted a health record-prohibited abbreviation lsit?
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Joint commission on Accreditation of healthcare organizations
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Which tupe of health record includes both paper & computerized components?
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Hybrid
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Which of the following is a disadvantage of an EHR over a paper-based record?
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Requires privacy & security measures
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In an integrated health record, documentation by health professionals is organized?
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Intermized in date sequence
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The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?
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Subjective
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Which of the following electronic record technological capabilities would allow an x-ray to be sent to a phsyciain in another state?
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Image processing
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Which of the following is true of paper-based records?
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They are susceptible to damage from fire or floods
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A definition of what constitutes a record, recording where each component is located & noting dates of format changes are particularly important in?
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Hybrid records
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In a problem-oriented health record, problems are organized by?
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Number
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Health level Seven (HL7) has developed guidelines that address which aspect of the electronic record?
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Definition of functions
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Which type of dat input mechanism is commonly used in both paper & electronic environment?
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