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26 Cards in this Set
- Front
- Back
Chapter 3
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Content and Structure of the Health Record
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Which of the following is a function of the health record?
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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 |
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Which of the following clinical data elements is not usually documented in the acute care health record?
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records of immunizations
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Which of the following is not a function of the discharge summary?
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providing information about the patient’s insurance coverage
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In which of the following ways can the patient’s consent to undergo treatment be expressed?
a. by his or her submission to treatment |
all of the above
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Which of the following would not be considered clinical data?
a. progress notes |
name of insurance company
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Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?
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The Health Insurance Portability and Accountability Act
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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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pathology report
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Which of the following is an example of an advance directive?
a. a living will |
an authorization to release information
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Which of the following materials is not documented in an emergency care record?
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patient’s instructions at discharge
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Which of the following types of facility is not governed by Medicare long-term care documentation standards?
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assisted living facilities
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Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?
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resident assessment protocol
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Which regulations are most commonly applied in end stage renal disease treatment?
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Medicare Conditions for Coverage
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Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?
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The incorrect information should be obliterated
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Which of the following types of healthcare facilities may seek accreditation from the Joint Commission?
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ambulatory care organizations
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The federal Conditions of Participation apply to which type of healthcare organization?
a. any organization that is accredited |
any organization that treats Medicare or Medicaid patients
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Which of the following is not a traditional health record format?
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integrated health record
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Which health record format is most commonly used by healthcare settings as they transition to electronic records?
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hybrid records
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Which of the following is not an example of a data capture technology?
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optical character readers
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Which of the following is a challenge in the implementation of computer-based records?
a. lack of standardization |
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 |
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Which of the following factors should be considered when designing a data retrieval system for an EHR?
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a. presentation of data
b. quick-search capabilities c. need to know d. analytical capabilities e. all of the above |
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What is the end result of a review process that shows voluntary compliance with guidelines of an external, nonprofit organization?
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accreditation
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Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(n) ____________ paper record
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integrated
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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 that patient’s own words?
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present illness
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Which of the following creates a chronological report of the patient’s condition and response to treatment during a hospital stay?
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progress notes
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Which of the following determines who can receive and transcribe verbal orders?
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licensure standards
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