HIT Chapter 3 Review

Flashcard maker : Ann Ricker
Which two major types of data are contained in the health record?

A. Nursing and physician

B. Administrative and clinical

C. Demographic and financial

D. Surgical and medical

B. Administrative and clinical
Which of the following terms refers to state or county regulations that healthcare facilities must meet to be permitted to provide care?

A. Accreditation

B. Bylaws

C. Certification

D. Licensure

D. Licensure
Which of the following is an accrediting organization?

A. State regulating agencies

B. American Health Information Management Association

C. Det Norske Veritas Healthcare

D. Centers for Medicare and Medicaid Services

C. Det Norske Veritas Healthcare
An accrediting organization is awarded deemed status by Medicare for one of its programs. This means that facilities receiving accreditation under its guidelines do not need to:

A. Meet licensure standards

B. Undergo Medicare certification surveys

C. Undergo accreditation surveys

D. Meet Medicare certification standards

B. Undergo Medicare certification surveys
Which group focuses on accreditation of managed care?

A. Accreditation Association for Ambulatory Healthcare

B. National Committee for Quality Assurance

C. Commission on Accreditation of Rehabilitation Facilities

D. The Joint Commission

B. National Committee for Quality Assurance
Which group focuses on accreditation of rehabilitation programs and services?

A. CARF

B. AOA

C. AAAHC

D. HFAP

A. CARF
Which of these accreditation organizations provides standards for the widest variety of healthcare facilities?

A. American Correctional Association

B. The Joint Commission

C. Accreditation Commission for Health Care

D. American Osteopathic Association

B. The Joint Commission
Which of the following would not be found in a medical history?

A. Chief complaint

B. Vital signs

C. Present illness

D. Review of systems

B. Vital signs
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report?

A. Consultation

B. Progress note

C. Operative report

D. Discharge summary

A. Consultation
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?

A. Flow record

B. Vital signs record

C. Care plan

D. Surgical note

C. Care plan
Written or spoken permission to proceed with care is classified as:

A. Expressed consent

B. Acknowledgment

C. Advance directive

D. Implied consent

A. Expressed consent
Which of the following reports provides information on tissue removed during a procedure?

A. Operative report

B. Laboratory report

C. Pathology report

D. Anesthesia report

C. Pathology report
Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records?

A. Obstetric

B. Newborn

C. Surgical

D. Emergency

B. Newborn
Which of the following is not considered patient demographic information?

A. Patient’s date of birth

B. Name of next of kin

C. Type of admission

D. Admitting diagnosis

D. Admitting diagnosis
Which of the following administrative documents provides information on the patient’s desires for healthcare for use if he/she is incapacitated?

A. Advance directive

B. Patient’s bill of rights

C. Notice of privacy practices

D. Authorization for release of information

A. Advance directive
Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient?

A. Ambulatory care

B. Emergency care

C. Long-term care

D. Rehabilitative care

B. Emergency care
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?

A. Ambulatory care

B. Emergency care

C. Long-term care

D. Rehabilitative care

A. Ambulatory care
The ambulatory surgery record contains information most similar to:

A. Physician’s office records

B. Emergency care records

C. Hospital operative records

D. Hospital obstetric records

C. Hospital operative records
Which standardized tool is used to assess Medicare-certified rehabilitation facilities?

A. Outcomes and Assessment Information Set (OASIS)

B. Care area assessment (CAA)

C. Patient assessment instrument (PAI)

D. Minimum Data Set (MDS)

B. Care area assessment (CAA)
Interdisciplinary care plans are an important part of which type of health record?

A. Emergency department

B. Ambulance

C. End-stage renal disease

D. Ambulatory care

C. End-stage renal disease
Portions of a treatment record may be maintained in a patient’s home in which two types of settings?

A. Hospice and behavioral health

B. Home health and hospice

C. Obstetric and gynecologic care

D. Rehabilitation and correctional care

B. Home health and hospice
A patient’s legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record?

A. Rehabilitative care

B. Ambulatory care

C. Behavioral health

D. Personal health

C. Behavioral health
Paper records may require thinning in which two settings?

A. Home health and hospice

B. Rehabilitation and end-stage renal disease

C. Ambulatory care and behavioral health

D. Long-term care and correctional services

D. Long-term care and correctional services
A growth and development record may be found in what type of record?

A. Rehabilitative care

B. Pediatric

C. Behavioral health

D. Obstetric

B. Pediatric
The document that indicates current and past medical conditions is:

A. MDS

B. CAAs

C. Problem list

D. PAI

C. Problem list
Which type of health record includes both paper and electronic components?

A. Hybrid

B. Electronic

C. Problem-oriented

D. Source-oriented

A. Hybrid
Which of the following is a disadvantage of an EHR over a paper-based record?

A. Allows customization to user needs

B. Permits multiple users at the same time

C. Enables duplicate copies to be made easily

D. Requires privacy and security measures

C. Enables duplicate copies to be made easily
In an integrated health record, documentation by health professionals is organized:

A. In sections by type of professional

B. In sections by problem number

C. Intermixed in date sequence

D. Depends on facility policy

C. Intermixed in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?
A. Subjective

B. Objective

C. Assessment

D. Plan

A. Subjective
Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state?

A. Database management

B. Image processing

C. Text processing

D. Vocabulary standards

B. Image processing
Which of the following is true of paper-based records?

A. They are susceptible to damage from fire or floods.

B. They lack standardization.

C. They are easy to access and update.

D. They require a limited number of personnel to process.

A. They are susceptible to damage from fire or floods.
A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in:

A. Electronic records

B. Integrated records

C. Paper records

D. Hybrid records

A. Electronic records
In a problem-oriented health record, problems are organized by:

A. Letter

B. Number

C. Patient name

D. Body system

B. Number

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