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24 Cards in this Set
- Front
- Back
Which type of standard is required of hospitals by states prior to providing any healthcare? |
Licensure |
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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 is not a function of the discharge summary? |
Providing information about the patient’s insurance coverage |
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Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? |
Laboratory findings |
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Which of the following would not be considered clinical data? |
Name of insurance company |
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Which of the following federal laws resulted in the new privacy regulations for healthcare organizations? |
The Health Insurance Portability and Accountability Act |
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Which includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? |
Operative report |
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Which materials is not documented in an emergency care record? |
Patient’s complete medical history |
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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? |
Outcomes and Assessment Information Set (OASIS) |
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Which regulations are most commonly applied in end-stage renal disease treatment? |
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? |
The incorrect information should be obliterated. |
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Which types of healthcare facilities may seek accreditation from the Joint Commission? |
Acute care hospitals, Psychiatric hospitals, Home care providers, and Ambulatory care organizations |
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The federal Conditions of Participation apply to which type of healthcare organization?
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Organizations that treat Medicare or Medicaid patients. |
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Which is not a traditional health record format? |
Process-oriented health record. |
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Which health record format is most commonly used by healthcare settings as they transition to electronic records? |
Hybrid records |
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Which of the following is an example of administrative information? |
The patient’s address |
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The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is:
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Plan |
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“Acute allergic reaction” would be documented in which part of a SOAP note? |
Assessment |
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What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization? |
Accreditation |
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Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) _________ paper record. |
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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Chief complaint |
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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? |
Progress notes |
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Which of the following determines who can receive and transcribe verbal orders? |
Medical staff bylaws |