Chapter 3

Front 1

Chapter 3

Back 1

Content and Structure of the Health Record

Front 2

Which of the following is a function of the health record?

Back 2

a. planning and managing care
b. evaluating the adequacy and appropriateness of care
c. substantiating reimbursement claims
d. protecting the legal interests of both patient and healthcare provider
e. all of the above

Front 3

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

Back 3

records of immunizations

Front 4

Which of the following is not a function of the discharge summary?

Back 4

providing information about the patient’s insurance coverage

Front 5

In which of the following ways can the patient’s consent to undergo treatment be expressed?
a. by his or her submission to treatment

Back 5

all of the above

Front 6

Which of the following would not be considered clinical data?
a. progress notes

Back 6

name of insurance company

Front 7

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

Back 7

The Health Insurance Portability and Accountability Act

Front 8

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

Back 8

pathology report

Front 9

Which of the following is an example of an advance directive?
a. a living will

Back 9

an authorization to release information

Front 10

Which of the following materials is not documented in an emergency care record?

Back 10

patient’s instructions at discharge

Front 11

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

Back 11

assisted living facilities

Front 12

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

Back 12

resident assessment protocol

Front 13

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

Back 13

Medicare Conditions for Coverage

Front 14

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 14

The incorrect information should be obliterated

Front 15

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

Back 15

ambulatory care organizations

Front 16

The federal Conditions of Participation apply to which type of healthcare organization?
a. any organization that is accredited

Back 16

any organization that treats Medicare or Medicaid patients

Front 17

Which of the following is not a traditional health record format?

Back 17

integrated health record

Front 18

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

Back 18

hybrid records

Front 19

Which of the following is not an example of a data capture technology?

Back 19

optical character readers

Front 20

Which of the following is a challenge in the implementation of computer-based records?
a. lack of standardization

Back 20

b. lack of a clear definition
c. organizational and behavioral resistance
d. difficulty meeting the needs of multiple end users
e. all of the above

Front 21

Which of the following factors should be considered when designing a data retrieval system for an EHR?

Back 21

a. presentation of data
b. quick-search capabilities
c. need to know
d. analytical capabilities
e. all of the above

Front 22

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

Back 22

accreditation

Front 23

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

Back 23

integrated

Front 24

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 24

present illness

Front 25

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

Back 25

progress notes

Front 26

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

Back 26

licensure standards