question

What is the primary purpose of patient health information?

answer

Patient care

question

Who is responsible for ensuring the quality of health record documentation?

answer

Provider

question

Which of the following statements about the legal health record or the designated records sent is incorrect?

answer

Designated records that is determined by the medical staff.

question

Of the following which is the most likely to happen to the health records of the physician's patient when a physician leaves and office practice?

answer

Retained by the practice

question

Once a paper health record has been converted onto microfilm, the information cannot be used as evidence

answer

FALSE

question

The legal health record:

answer

Will be disclosed upon request

question

The legal health record must meet requirements as defined by the following:

answer

All of the above

question

Verbal orders by telephone or in person or discouraged. In cases were verbal orders are necessary, which of the following is the most effective method by which the risk of miscommunication can be lessened?

answer

Person receiving the order should read it back to ensure that the order is correct

question

Which of the following exemplifies an acceptable patient record entry?

answer

Patient articulated pain level as of six

question

Every report in the patient record must contain patient identification data.

answer

TRUE

question

The Uniform Rules of Evidence states that for a record to be admissible in court of law, all patient record entries must be dated and timed.

answer

TRUE

question

And advanced directive and an informed consent are considered clinical data

answer

FALSE

question

The admitting diagnosis is the condition or disease for which the patient is seeking treatment.

answer

TRUE

question

Third-party payer information is classified as financial data, and it is obtained from the patient at admission

answer

TRUE

question

A complication is a pre-existing condition that will cause an increase in the patient's length of stay by at least one day

answer

FALSE

question

The principal procedure is performed for definitive or therapeutic reasons

answer

TRUE

question

Health information personnel who extract records assign ICD -9 - CM codes to diagnoses and procedures

answer

FALSE

question

The Healthcare Financing Administration is now called the centers for Medicare and Medicaid Services

answer

TRUE

question

Up coding or maximizing codes is considered DRG Creep

answer

TRUE

question

The Patient Self - Determination Act of 1990 requires all healthcare facilities to notify patients age 21 and over that they have the right to have an advance directive

answer

FALSE

question

A living will is a written document informs a healthcare provider of the patient's desires regarding life - sustaining treatment

answer

TRUE

question

Persons under 18 years of age must have their parents or guardian consent to donate organs

answer

TRUE

question

The Joint Commission Standards requires a patient's consent to treatment and that the record contain evidence of consent

answer

TRUE

question

A consent to admission documents the patient's consent for all medical treatment including procedures and surgeries to be completed during the current admission

answer

FALSE

question

The National Center for Health Statistics developed a standard certificate of birth that states adopt for their use

answer

TRUE

question

AOA requirements state for the patient record must be maintained for each patient treated in emergency department

answer

TRUE

question

A discharge progress note can be documented in the patient record instead of the discharge summary if the patient had an uncomplicated hospital stay of less than 48 hours

answer

TRUE

question

A delinquent records can result in suspension of a physician's medical staff privileges

answer

TRUE

question

The history of the present illness is the patient's description of their current medical condition in their own words

answer

FALSE

question

A consultation includes the examination of the patient by specialist who also provides an opinion or advice

answer

TRUE

question

All orders must be authenticated by the responsible provider

answer

TRUE

question

Integrated progress notes are documented by physicians, nurses, therapists, and other professionals in the same section of the patient record

answer

TRUE

question

An admission note documented by the attending physician can replace a dictated history and physical examination

answer

FALSE

question

Pre-anesthesia and post anesthesia progress notes are often documented on a separate form to facilitate documentation by the anesthesiologist

answer

TRUE

question

The pathology report assists in the diagnosis and treatment of patients by documenting analysis of tissue removed surgically

answer

TRUE

question

The name of the attending physician is considered patient identification information

answer

FALSE

question

Electro cardiogram (EKG) reports include a graphic print out of measurements of electrical activity of the brain

answer

FALSE

question

All ancillary reports should be filed in the patient's record within 24 hours after interpretation of test results

answer

TRUE

question

The postpartum record is started in the physicians office and includes all tests performed, pregnancy risks, and care given

answer

FALSE

question

The documentation of emergency services provided prior to admission is considered clinical/case information

answer

TRUE

question

Medicare Conditions of Participation (CoP) categorize outpatient care as optional hospital services and require the hospital to maintain a medical record for each outpatient

answer

TRUE

question

The appearance of an outpatient to a hospital department is called an encounter

answer

FALSE

question

A licensed nurse is required to have a public license to deliver care to patients

answer

TRUE

question

The role of the forms committee is to review all proposed forms to be used in the patient record

answer

TRUE

question

Ready - to - use forms are often more expensive to purchase and therefore are not used by many facilities

answer

FALSE

question

The patient history documents the patient's chief complaint, history of the present illness, past/family/social history, and review of systems

answer

TRUE

question

Progress notes facilitate healthcare team communication, which is crucial to quality care

answer

TRUE

question

The forms committee oversees the process of new forms control and design

answer

TRUE

question

The death certificate is usually filed with state Department of Health office of vital statistics within five days

answer

TRUE

question

Which is an example of clinical data?

answer

Anesthesiology report

question

Which statement regarding the patient record is true

answer

All entries must be legible and complete

question

The diagnosis that documents the condition or disease for which the patient is seeking treatment is the

answer

Provisional diagnosis

question

A pre-existing condition that causes an increase in the patient's length of stay by at least one day in 75% of the cases is known as

answer

Comorbidity

question

The name, address, phone number of the third - party payer is considered

answer

Financial data

question

Every report and every page/screen in the manual or computerized patient record must include

answer

Patient name and identification number

question

The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the

answer

Uniform Hospital Discharge Data Set

question

A patient is admitted for congestive heart failure and hypertension. During the admission the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a:

answer

comorbidity

question

The document that informs a healthcare provider of the patient's desire regarding various life - sustaining treatment is a:

answer

Living Will

question

The process of advising a patient about treatment options is known as

answer

Informed consent

question

Sally Smith is admitted to Sunny Valley Hospital wearing a diamond ring. This should be documented on the

answer

Patient property form

question

Birth certificate information is usually submitted to the ______ within 10 days of birth

answer

State Department of health or offices of vital statistics

question

The joint commission requires the discharge summary be completed within _______ days of discharge

answer

30

question

Dr. Smith has 10 patient records that are delinquent. The action that could be taken by the hospital includes

answer

Suspension of physician privileges

question

When a patient is transferred to a different level of care within the same hospital, the summary report is called a:

answer

Transfer summary

question

Dr. Jones completes an admission history and physical on Bob Lot, who states, "when I walk upstairs, I have difficulty breathing." This statement is known as the patient's

answer

Chief complaint

question

Progress note should be written:

answer

as the patient's condition warrants

question

An Apgar score is documented in the:

answer

Newborn record

question

Information concerning the mother's condition after delivery is documented in the:

answer

Postpartum record

question

The provisional autopsy report should be documented within

answer

Three days

question

The major responsibility of a complete and accurate record rests with the

answer

Attending physician

question

Sunny Valley hospital has adopted the following as part of its patient record documentation guidelines. Determine which guidelines need to be revised because they do not reflect sound documentation practices

answer

Complete only necessary entries on preprinted forms. And if other patients are referenced in the record, document their names

question

Review the following patient record entry, and determine which report it would be documented: Skin No jaundice reveals pale, cool, and moist surface Chest Respirations normal Lung Clear on inspection, percussion, and auscultation Abdomen No tenderness, guarding, or rigidity Extremities No significant findings Genitalia Normal Rectal Deferred

answer

Physical examination

question

Dr. Smith enters the following information as part of a progress note: 2/3/why why why. Patient complains of right upper abdominal pain of four days duration. This information represents the:

answer

Chief complaint

question

A patient's record contains the following order: "Mary Black is stable and has no complaints of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks. This is an example of the a:

answer

Discharge order

question

Dr. Smith documents the patient's record that the patient may be released from the recovery room. This would be documented as part of the

answer

Post anesthesia note

question

Which of the following statements would be found as part of the preanesthesia note?

answer

Patient denies any previous reactions to anesthesia, anesthesia is to be used - Gen., patient is at risk due to smoking history

question

Dr. Jones reviews the following information located in the patient record. Determine which report the information is documented. Insert photograph

answer

Vital signs record

question

The following note is written by Dr. Balby: onset of contractions started at 4 AM. Patient refused medications. Normal presentation. Outcome of delivery: single male infant. This information would be documented as part of the

answer

Labor and delivery record

question

Dr. Health sees Jack in her office to monitor his blood chemistry. She completes an examination and orders blood tests. Her medical assistant completes the venipuncture. Charges for the services would be recorded on an:

answer

Encounter form

question

Sally Jones assembles the patient record and organizes the following documents into a separate section of the record: facesheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered:

answer

Administrative data

question

Ms. RHIT is developing an audit tool to be used to review records in preparation for the joint commission survey. Which of the following is standard that should be included on the audit tool?

answer

The record needs to document evidence of appropriate informed consent

question

The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient waits on the day of admission as well as date of discharge. This information can be located on the:

answer

Graphic record

question

Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the:

answer

Forms committee

question

Sally Smith is completing analysis of the patient's record and finds an original incident report in the record. Which action should you take?

answer

Send the original incident report to risk managers office

question

Dr. Cook records the following as part of the history and physical examination: patient presents with abdominal pain of seven days duration. Fever and chills for the last three days. Diagnoses at the time of admission: rule out appendicitis versus obstruction of colon. The diagnoses recorded are:

answer

differential diagnoses

question

Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Hart, a cardiologist, to evaluate Mary's chest pain. Dr. Hart would document his examination of the patient, pertinent findings, recommendations, and opinions on the:

answer

Report of consultation

question

Nurse Smith believes that inpatient Tom Jones needs to have physical therapy because his gait is unsteady when she works him. Which of the following would occur?

answer

Nurse Smith should discuss your observations with Tom's attending physician

question

In which of the following cases with documentation of an interval history be acceptable?

answer

74 - year - old readmitted for pneumonia seven days following discharge for this condition

question

Which of the following observations would be found in the physical examination report?

answer

Abdomen soft and tender with no rebound tenderness

question

Which of the following is not documented as part of a consultation report?

answer

Signature of requesting physician

question

"As Ms. RHIT assembles and analyzes a discharge obstetrical patient's record, she finds the forms listed below. Which should be pulled from the discharge patients record? Facesheet Admission history and physical exam Consents Patients property record Insurance claim Laboratory reports Antepartum record copy Labor and delivery record Incident report Postpartum record

answer

Incident report and insurance claim

question

A patient was admitted with chronic obstructive pulmonary disease COPD on April 15 this year. The patient has an exacerbation of COPD and was readmitted on June 1 this year. The physician needs to document an:

answer

History and physical examination

question

Molly makes was admitted to Sun Valley Hospital on January 22 this year for pneumonia. The history and physical examination of HNP was placed on the record January 24 this year. Determine which of the following statements is true based on joint commission standards

answer

The record is not in compliance, as the H&P needs to be completed within 24 hours

question

Ms. RHIT is analyzing and assembling to patients record and notices the copy of the history and physical from the attending physician's office was used in the record instead of an inpatient history and physical. The office H&P was completed on January 2 this year and the patient was admitted to the hospital on January 5 this year; the office H&P was placed on the record at the time of admission. According to Medicare CoP regulations, the office H&P is:

answer

Acceptable as the H&P for this admission because it was completed no more than seven days prior to admission

question

Which of the following is documented on the physical examination?

answer

Patient's lungs are congested

question

Which of the following would not be documented on the medication administration record?

answer

Provisional diagnosis

question

Which of the following documents that the patient acknowledges the nature of treatment, risk, and complications of care?

answer

Consent

question

The hospital record that documents diagnostic, therapeutic, and rehabilitation services of outpatients is the:

answer

Ambulatory record

question

Dr. Smith wants to implement a new form to record post operative complications. This should be reviewed to be approved for use in medical record by the:

answer

forms committee

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