Content And Structure Of The Health Record

Front 1

Which type of standard is required of hospitals by states prior to providing any healthcare?

Back 1

Licensure

Front 2

Which of the following clinical data elements is not usually documented in the acute-care health record?

Back 2

Records of immunizations

Front 3

Which is not a function of the discharge summary?

Back 3

Providing information about the patient’s insurance coverage

Front 4

Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?

Back 4

Laboratory findings

Front 5

Which of the following would not be considered clinical data?

Back 5

Name of insurance company

Front 6

Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?

Back 6

The Health Insurance Portability and Accountability Act

Front 7

Which includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?

Back 7

Operative report

Front 8

Which materials is not documented in an emergency care record?

Back 8

Patient’s complete medical history

Front 9

Which of the following types of facility is not generally governed by long-term care documentation standards?

Back 9

Assisted living facilities

Front 10

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

Back 10

Outcomes and Assessment Information Set (OASIS)

Front 11

Which regulations are most commonly applied in end-stage renal disease treatment?

Back 11

Medicare Conditions for Coverage

Front 12

Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?

Back 12

The incorrect information should be obliterated.

Front 13

Which types of healthcare facilities may seek accreditation from the Joint Commission?

Back 13

Acute care hospitals, Psychiatric hospitals, Home care providers, and Ambulatory care organizations

Front 14

The federal Conditions of Participation apply to which type of healthcare organization?

Back 14

Organizations that treat Medicare or Medicaid patients.

Front 15

Which is not a traditional health record format?

Back 15

Process-oriented health record.

Front 16

Which health record format is most commonly used by healthcare settings as they transition to electronic records?

Back 16

Hybrid records

Front 17

Which of the following is an example of administrative information?

Back 17

The patient’s address

Front 18

The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is:

Back 18

Plan

Front 19

“Acute allergic reaction” would be documented in which part of a SOAP note?

Back 19

Assessment

Front 20

What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?

Back 20

Accreditation

Front 21

Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) _________ paper record.

Back 21

Integrated

Front 22

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 that patient’s own words?

Back 22

Chief complaint

Front 23

Which of the following creates a chronological report of the patient’s condition and response to treatment during a hospital stay?

Back 23

Progress notes

Front 24

Which of the following determines who can receive and transcribe verbal orders?

Back 24

Medical staff bylaws