HIM Chapter 4 – Flashcards
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The overall goal of documentation standard is?
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To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient.
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A hospital that participates in the Medicare and Medicaid programs must follow?
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The conditions of participation
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When defining it's legal Health record, a healthcare provider organization must do which of the following?
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Assess the legal environment, System limitations, and HIE agreements
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Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists the patient's past medical, personal, and family history?
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Medical history
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General documentation guidelines apply to?
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All categories of health care records
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True or false? Only individuals authorized by the organizations policies should be allowed to enter documentation in the health record
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True
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True or false? Healthcare entries should be documented at the time the services they describe are rendered
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True
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True or false? auto authentication is the preferred method of authentication
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False
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Which of the following creates a chronological report of the patient's condition and response to treatment during the hospital stay?
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Progress notes
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Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in the patient's own words?
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Chief complaint
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Which of the following is an example of administrative information?
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Patients address
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The federal conditions of participation apply to which type of healthcare organization?
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Organizations that treat Medicare or Medicaid Patients
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Which of the following materials is documented in an emergency care record?
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Time and means of the patient's arrival
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Which of The following statements is true of the process that should be followed in making corrections in paper based health record entries?
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The phrase "late entry" should be noted on the entry
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Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?
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Operative report
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Which of the following types of facilities is generally governed by long-term care documentation standards?
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Rehabilitation
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Which of the following is a function of the discharge summary?
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Providing information to support the activities of the medical staff review committee
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A patient registration forms, personal property list, RAI/MDS and care plan and discharge or transfer documentation would be found most frequently in which type of health record?
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Long-term care
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Which group focuses on accreditation of rehabilitation programs and services?
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CARF
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Results of the urinalysis and I'll blood test performed would be found and what part of the health care record?
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Laboratory findings
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Which of the following is clinical data?
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Physician orders
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Documentation standards have become more detailed and have become focused on?
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Patient care quality
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Written or spoken permission to proceed with care is classified as?
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Expressed consent
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Consent to treatment
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Means that the patient gives the physician or other healthcare provider permission to touch them.
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Authorizations
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Is a document that is required under the privacy rule of the health information portability and accountability act for the use and disclosure of protected health information
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Acknowledgments
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Our documents that the patient or the patient's authorize personal representative sign confirming the receipt of an important and applicable information
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What are the acknowledgments that the patient receives?
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Notice of privacy practices, patient rights, property and valuables list
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Authentication
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Is the process of identifying the source of health record entrance by attaching a handwritten signature, the authors initials, or electronic signature
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The joint commission places emphasis on?
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Clinical and operational practices related to the health record
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Which of the following electronic record technical-logical capabilities would allow a paper based x-ray report to be accessed?
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Document imaging
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The subjective, objective, assessment plan came from the?
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Problem - oriented health record
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Overall goal of documentation standard is to?
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Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
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What standard does a hospital that participates in Medicare and Medicaid programs have to comply with that hospitals who do not except Medicare and Medicaid patients do not?
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Medical bylaws of the healthcare provider organization
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Which of the following is an example of an acknowledgment?
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Notice of privacy practices
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The management of health information is a fundamental component of which of the following?
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The overall information governance model
