HIM CHAPTER 6

Flashcard maker : Robert Lollar
The process of advising a patient about treatment options is known as
a.
patient consent.
b.
treatment consent.
c.
applied consent.
d.
informed consent.
d. informed consent
Sally Smith is admitted to Sunny Valley Hospital wearing a diamond ring. This should be documented on the
a.
patient property form.
b.
nursing assessment.
c.
financial record.
d.
face sheet.
a. patient property form
Birth certificate information is usually submitted to the ____ within 10 days of birth.
a.
National Center for Health Statistics
b.
National Center for Birth Statistics
c.
state departments of health or offices of vital statistics
d.
admissions office
C
The Joint Commission requires that a discharge summary be completed within ____ days of discharge.
a.
25
b.
15
c.
30
d.
20
c. 30
Dr. Smith has 10 patient records that are delinquent. The action that could be taken by the hospital includes
a.
suspension of license.
b.
suspension of physician privileges.
c.
revoking the physician’s license.
d.
denial of clinical privileges.
b.
When a patient is transferred to a different level of care within the same hospital, the summary report is called a:
a.
progress summary
b.
discharge summary
c.
transfer summary
d.
level of care summary
c
Dr. Jones completes an admission history and physical on Bob Lot, who states, \”When I walk up stairs, I have difficulty breathing.\” This statement is known as the patient’s
a.
patient complaint.
b.
chief complaint.
c.
past history.
d.
history of the present illness.
b.
Progress notes should be written
a.
on admission and discharge.
b.
weekly.
c.
as the patient’s condition warrants.
d.
daily.
c
An Apgar score is documented in the
a.
admission history and physical.
b.
autopsy report.
c.
nursing assessment.
d.
newborn record.
d
Information concerning the mother’s condition after delivery is documented in the
a.
labor record.
b.
postpartum record.
c.
antepartum record.
d.
delivery record.
b
The provisional autopsy report should be documented within
a.
three days.
b.
60 days.
c.
48 hours.
d.
one week.
a
The major responsibility of a complete and accurate record rests with the
a.
medical staff committee.
b.
attending physician.
c.
medical director.
d.
director of HIM.
b
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.

1. All entries should be documented and signed by the author.
2. Complete only necessary entries on preprinted forms. Leave others blank.
3. If other patient(s) are referenced in the record, document their name(s).
4. All documentation should be entered in permanent black ink.
5. Be sure to document specific information and to avoid vague entries.

a.
2 and 3
b.
2 and 5
c.
1 and 4
d.
1 and 2

a
Review the following patient record entry, and determine in which report it would be documented.

Skin No jaundice reveals pale, cool, and moist surface.
Chest Respirations normal.
Lungs Clear on inspection, percussion, and auscultation.
Abdomen No tenderness, guarding, or rigidity.
Extremities No significant findings.
Genitalia Normal.
Rectal Deferred.

a.
physical examination
b.
review of systems
c.
chief complaint
d.
history of present illness

A
Dr. Smith enters the following information as part of a progress note: \”2/3/YYYY Patient complains of right upper abdominal pain of four days’ duration.\” This information represents the
a.
interval history.
b.
physical examination.
c.
chief complaint.
d.
history of present illness.
C.
A patient’s record contains the following order: \”Mary Black is stable and has no complaint 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 a
a.
transfer order.
b.
discharge order.
c.
stop order.
d.
routine order.
B
Dr. Smith documents in a patient’s record that the patient may be released from the recovery room. This would be documented as part of the
a.
operative report.
b.
postanesthesia note.
c.
postoperative note.
d.
progress notes.
B
Which of the following statements would be found as part of a preanesthesia note?
1. Patient denies any previous reactions to anesthesia.
2. Anesthesia to be used-general.
3. Patient had no reaction to current surgery.
4. Patient is at risk due to smoking history.
a.
2 and 3
b.
1, 2, and 3
c.
1 and 2
d.
1, 2, and 4
D
Dr. Jones reviews the following information located in the patient record. Determine in which report the information is documented.

Date 1/2/YYYY 1/3/YYYY 1/4/YYYY 1/5/YYYY 1/6/YYYY 1/7/YYYY
Blood Pressure 130/75 128/78 120/75 130/80 135/80 130/78
Temperature 99.3 99.5 99.8 99.5 99.8 99.9
Weight 139 139 137 137 136 138

a.
physical examination
b.
vital signs record
c.
history of present illness
d.
nursing care plan

B
The following note is written by Dr. Balby: \”Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant.\” This information would be documented as part of the
a.
postpartum record.
b.
antepartum record.
c.
labor and delivery record.
d.
prenatal record.
C
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 these services would be recorded on a(n)
a.
encounter form.
b.
superslip.
c.
face sheet.
d.
fee schedule.
A
Sally Jones assembles a patient record and organizes the following documents into a separate section of the record: face sheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered
a.
financial data.
b.
miscellaneous data.
c.
administrative data.
d.
clinical data.
C
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 a standard that should be included on the audit tool?
a.
The discharge summary must be completed within 35 days of discharge.
b.
Each record needs to include a statistical summary sheet.
c.
The record needs to document evidence of appropriate informed consent.
d.
The attending physician must sign an attestation statement.
C
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 weights on the day of admission as well as day of discharge. This information can be located on the
a.
intake/output record.
b.
graphic record.
c.
nursing progress notes.
d.
discharge summary.
B
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
a.
surgery committee.
b.
forms committee.
c.
executive board.
d.
medical staff.
B
Sally Smith is completing analysis of a patient’s record and finds an original incident report in the record. Which action should she take?
a.
Make a copy of the incident report for the risk manager and file the original in the record.
b.
Send the original incident report to the risk manager’s office.
c.
File the original incident report in the patient record.
d.
Make a copy of the incident report for the patient’s record and send the original to the risk manager.
B
Dr. Cook records the following as part of a history and physical examination: \”Patient presents with abdominal pain of seven days’ duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out appendicitis vs. obstruction of colon.\” The diagnoses recorded are
a.
secondary diagnoses.
b.
differential diagnoses.
c.
admission diagnoses.
d.
primary diagnoses.
B
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. Heart, a cardiologist, to evaluate Mary’s chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the
a.
report of consultation.
b.
interval history and physical.
c.
review of systems.
d.
discharge summary.
A
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?
a.
Nurse Smith should change the nursing care plan to include physical therapy.
b.
Nurse Smith should schedule Tom to be seen by the hospital physical therapist.
c.
Nurse Smith should discuss her observations with Tom’s attending physician.
d.
Nurse Smith should begin bedside physical therapy for the patient.
C
In which of the following cases would documentation of an interval history be acceptable?
a.
74-year-old readmitted for pneumonia seven days following discharge for this condition.
b.
34-year-old woman readmitted for chest pain following delivery of a baby girl three days ago.
c.
Newborn admitted four days after birth for dehydration who is treated with IV fluids.
d.
17-year-old patient admitted for appendicitis who undergoes routine surgery during admission.
A
Which of the following observations would be found in the physical examination report?
a.
Abdomen soft and tender with no rebound tenderness.
b.
Has smoked two packs of cigarettes daily for past 30 years.
c.
Needs assistance to perform activities of daily living.
d.
Review of systems negative for hypertension and diabetes.
A
Which of the following is not documented as a part of a consultation report?
a.
consulting physician’s signature
b.
diagnosis and findings
c.
signature of requesting physician
d.
recommendations and opinions
C
As Ms. RHIT assembles and analyzes a discharged obstetrical patient’s record, she finds the forms listed below. Which should be pulled from the discharged patient’s record?

Face sheet
Admission history and physical exam
Consents
Patient’s property record
Insurance claim
Laboratory reports
Antepartum record (copy)
Labor and delivery record
Incident report
Postpartum record
a.
incident report and antepartum record (copy)
b.
antepartum record (copy), insurance claim, and incident report
c.
incident report and insurance claim
d.
antepartum record (copy)

C
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 a(n)
a.
progress note discussing patient’s condition since April 15.
b.
interval history and physical examination.
c.
short form history and physical examination.
d.
history and physical examination.
D
Molly Mapes was admitted to Sunny Valley Hospital on January 22 (this year) for pneumonia. The history and physical examination (H&P) was placed on the record January 24 (this year). Determine which of the following statements is true, based on Joint Commission standards.
a.
The record is not in compliance, as the H&P needs to be completed within 12 hours.
b.
The record is in compliance, as the H&P needs to be completed within 48 hours.
c.
The record is not in compliance, as the H&P needs to be completed within 24 hours.
d.
The record is in compliance, as the H&P needs to be completed within 72 hours.
C
Ms. RHIT is analyzing and assembling a patient’s record and notices that a copy of a 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
a.
acceptable as the H&P for this admission because it was placed on the record within 24 hours.
b.
unacceptable because the office H&P was not completed within 24 hours prior to admission.
c.
unacceptable because only a newly documented inpatient history and physical is acceptable.
d.
acceptable as the H&P for this admission because it was completed no more than seven days prior to admission.
D
Which of the following is documented on the physical examination?
a.
Denies loss of hearing.
b.
Patient’s lungs are congested.
c.
Zocar, 40 mg, daily
d.
\”I’m feeling very tired lately.\”
B
Which of the following would not be documented on a medication administration record?
a.
provisional diagnosis
b.
nurse who administered medication
c.
dosage given
d.
medication given
A
Which of the following documents that the patient acknowledges the nature of treatment, risk, and complications of care?
a.
history and physical
b.
admission face sheet
c.
consent
d.
discharge summary
C
The hospital record that documents diagnostic, therapeutic, and rehabilitation services of outpatients is the:
a.
discharge summary
b.
ambulatory record
c.
short stay summary
d.
inpatient record
B
Dr. Smith wants to implement a new form to record postoperative complications. This should be reviewed to be approved for use in the medical record by the:
a.
tissue committee
b.
forms committee
c.
supervising operating room nurse
d.
medical director
B
Which is an example of clinical data?

a. advance directive
b. anesthesiology report
c. informed consent
d. patient property form

B
Which statement regarding the patient record is true?

a. Only the front page of a two-page document must contain patient identification.
b. An alias cannot be used in a patient record.
c. All entries must be legible and complete.
d. The author of each entry does not have to sign the note if another supervising professional has signed it.

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

a. final diagnosis.
b. discharge diagnosis.
c. provisional diagnosis.
d. preoperative diagnosis.

C
A preexisting 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 a

a. comorbidity.
b. principal diagnosis.
c. complication.
d. chief complaint.

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

a. identification data.
b. supplemental data.
c. demographic data.
d. financial data.

D
Every report and every page/screen in a manual or computerized patient record must include
a. patient name and identification number.
b. patient name and date of birth.
c. medical record number and Social Security number.
d. medical record number and date of birth.
A
The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the
a. Uniform Hospital Discharge Data Set.
b. Medicare/Medicaid Discharge Data Set.
c. Medicare/Medicaid Core Data Set.
d. Hospital Core Data Set.
A
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

a. principal diagnosis.
b. comorbidity.
c. principal condition.
d. complication.

B
A document that informs a health care provider of a patient’s desire regarding various life-sustaining treatment is a

a. organ donation card.
b. do not resuscitate order.
c. living will.
d. health care proxy.

C

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