Deck 6: Content of the Patient Record: Inpatient, Outpatient, and Physician Office

Question 1

A delinquent record can result in suspension of a physician's medical staff privileges.

Answer 1

True

Question 2

The Health Care Financing Administration is now called the Centers for Medicare and Medicaid Services.

Answer 2

True

Question 3

The Patient Self Determination Act of 1990 required that all health care facilities notify patients age 18 and over that they have the right to have an advance directive placed in their record.

Answer 3

True

Question 4

The Patient Self-Determination Act of 1990 requires all health care facilities to notify patients age 21 and over that they have the right to have an advance directive.

Question 5

The National Center for Health Statistics developed a standard certificate of birth that states adopt for their use.

Question 6

The Joint Commission standards require a patient's consent to treatment and require that the record contain evidence of consent.

Question 7

The Uniform Rules of Evidence states that for a record to be admissible in a court of law, all patient record entries must be dated and timed.

Question 8

Every report in the patient record must contain patient identification data.

Question 9

Clinical data contains all health care information obtained about a patient's care and treatment.

Question 10

Third-party payer information is classified as financial data, and it is obtained from the patient at admission.

Question 11

The history of the present illness is the patient's own description of his or her current medical condition.

Question 12

The admitting diagnosis is the condition or disease for which the patient is seeking treatment.

Question 13

A living will is a written document that informs a health care provider of a patient's desires regarding life-sustaining treatment.

Question 14

A principal procedure is performed for definitive or therapeutic reasons.

Question 15

A complication is a preexisting condition that will cause an increase in the patient's length of stay by at least one day.

Question 16

Persons under 18 years of age must have their parents' or guardian's consent to donate organs.

Question 17

An advance directive and an informed consent are considered clinical data.

Question 18

A consent to admission documents a patient's consent for all medical treatment including procedures and surgeries to be completed during the current admission.

Question 19

Health information personnel who abstract records assign ICD-10-CM codes to diagnoses and procedures.

Question 20

Upcoding or maximizing codes is considered DRG creep.

Question 21

The pathology report assists in the diagnosis and treatment of patients by documenting analysis of tissue removed surgically.

Question 22

The forms committee oversees the process of new forms control and design.

Question 23

Electrocardiogram (EKG) reports include a graphic printout of measurements of the electrical activity of the brain.

Question 24

The role of a forms committee is to review all proposed forms to be used in the patient record.

Question 25

The postpartum record is initiated in the physician's office and includes all tests performed, pregnancy risks, and care given.

Question 26

All ancillary reports should be filed in the patient's record within 24 hours after interpretation of test results.

Question 27

The patient history documents the patient's chief complaint, history of present illness, past/family/social history, and review of systems.

Question 28

Ready-to-use forms are often more expensive to purchase and therefore are used by few facilities.

Question 29

The appearance of an outpatient to a hospital department is called an encounter.

Question 30

Integrated progress notes are documented by physicians, nurses, therapists, and other professionals in the same section of the patient record.

Question 31

Medicare Conditions of Participation (CoP) categorize outpatient care as optional hospital services and require the hospital to maintain a medical record for each outpatient.

Question 32

All orders must be authenticated by the responsible provider.

Question 33

The death certificate is usually filed with a state department of health's office of vital statistics within five days.

Question 34

A consultation includes the examination of a patient by a specialist, who also provides an opinion or advice.

Question 35

The name of the attending physician is considered patient identification information.

Question 36

An admission note documented by the attending physician can replace a dictated history and physical examination.

Question 37

Progress notes facilitate health care team communication, which is crucial to quality care.

Question 38

The documentation of emergency services provided prior to admission is considered clinical/case information.

Question 39

Pre-and post-anesthesia progress notes are often documented on a separate form to facilitate documentation by the anesthesiologist.

Question 40

A licensed nurse is required to have a public license to deliver care to patients.

Question 41

The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the

A) Hospital Core Data Set.
B) Medicare/Medicaid Core Data Set.
C) Medicare/Medicaid Discharge Data Set.
D) Uniform Hospital Discharge Data Set.

Question 42

Dr. Smith has 10 delinquent patient records. Actions that could be taken by the hospital include

A) denial of clinical privileges.
B) suspension of license.
C) suspension of physician privileges.
D) revoking the physician's license.

Question 43

An autopsy would be performed in all of the following cases except

A) pediatric death.
B) cancer patient.
C) sudden infant death.
D) death that occurs in operating room.

Question 44

The name, address, and phone number of the third-party payer is considered

A) demographic data.
B) financial data.
C) identification data.
D) supplemental data.

Question 45

When a patient is transferred to a different level of care within the same hospital, the summary report is called a

A) discharge summary.
B) progress summary.
C) transfer summary.
D) level of care summary.

Question 46

A document that informs a health care provider of a patient's desire regarding various life-sustaining treatment is a

A) do not resuscitate order.
B) health care proxy.
C) living will.
D) organ donation card.

Question 47

A patient is admitted for congestive heart failure and hypertension. During the admission, the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a

A) complication.
B) comorbidity.
C) principal condition.
D) principal diagnosis.

Question 48

The Joint Commission requires that a discharge summary be completed within ____ days of discharge.

A) 15
B) 20
C) 25
D) 30

Question 49

Progress notes should be written

A) daily.
B) weekly.
C) on admission and discharge.
D) as the patient's condition warrants.

Question 50

The process of advising a patient about treatment options is known as

A) applied consent.
B) informed consent.
C) patient consent.
D) treatment consent.

Question 51

Which is an example of clinical data?

A) Advance directive
B) Anesthesiology report
C) Informed consent
D) Patient property form

Question 52

Sally Smith is admitted to Sunny Valley Hospital wearing a diamond ring. This should be documented on the

A) face sheet.
B) financial record.
C) patient property form.
D) nursing assessment.

Question 53

Dr. Jones completes an admission history and physical on Bob Lot, who states, "When I walk up stairs, I have difficulty breathing." This statement is known as the patient's

A) chief complaint.
B) history of the present illness.
C) past history.
D) patient complaint.

Question 54

Information concerning the mother's condition after delivery is documented in the

A) antepartum record.
B) delivery record.
C) labor record.
D) postpartum record.

Question 55

Which statement regarding the patient record is true?

A) All entries must be legible and complete.
B) An alias cannot be used in a patient record.
C) Only the front page of a two-page document must contain patient identification.
D) The author of each entry does not have to sign the note if another supervising professional has signed it.

Question 56

Birth certificate information is usually submitted to the ____ within 10 days of birth.

A) admissions office
B) National Center for Health Statistics
C) National Center for Birth Statistics
D) state departments of health or offices of vital statistics

Question 57

An APGAR score is documented in the

A) admission history and physical.
B) autopsy report.
C) newborn record.
D) nursing assessment.

Question 58

Every report and every page/screen in a manual or computerized patient record must include

A) medical record number and date of birth.
B) medical record number and Social Security number.
C) patient name and date of birth.
D) patient name and identification number.

Question 59

A preexisting condition that causes an increase in the patient's length of stay by at least one day in 75% of the cases is known as a

A) chief complaint.
B) complication.
C) comorbidity.
D) principal diagnosis.

Question 60

The diagnosis that documents the condition or disease for which the patient is seeking treatment is the

A) discharge diagnosis.
B) final diagnosis.
C) provisional diagnosis.
D) preoperative diagnosis.

Question 61

Sally Smith is completing analysis of a patient's record and finds an original incident report in the record. Which action should she take?

A) File the original incident report in the patient record.
B) Make a copy of the incident report for the patient's record, and send the original to the risk manager.
C) Make a copy of the incident report for the risk manager, and file the original in the record.
D) Send the original incident report to the risk manager's office.

Question 62

Dr. Smith documents in a patient's record that the patient may be released from the recovery room. This would be documented as part of the

A) operative report.
B) postanesthesia note.
C) postoperative note.
D) progress notes.

Question 63

Dr. Jones reviews the following information located in the patient record. In which report is the information documented? $\begin{array}{|l|l|l|l|l|l|l|}\hline \text { Date } & 1 / 2 / \mathrm{YYYY} & 1 / 3 / \mathrm{YYYY} & 1 / 4 / \mathrm{YYYY} & 1 / 5 / \mathrm{YYYY} & 1 / 6 / \mathrm{YYYY} & 1 / 7 / \mathrm{YYYY} \\\hline \text { Blood Pressure } & 130 / 75 & 128 / 78 & 120 / 75 & 130 / 80 & 135 / 80 & 130 / 78 \\\hline \text { Temperature } & 99.3 & 99.5 & 99.8 & 99.5 & 99.8 & 99.9 \\\hline \text { Weight } & 139 & 139 & 137 & 137 & 136 & 138 \\\hline\end{array}$

A) History of present illness
B) Physical examination
C) Nursing care plan
D) Vital signs record

Question 64

Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Heart, a cardiologist, to evaluate Mary's chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the

A) discharge summary.
B) interval history and physical.
C) report of consultation.
D) review of systems.

Question 65

Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the

A) executive board.
B) forms committee.
C) medical staff.
D) surgery committee.

Question 66

Sally Jones assembles a patient record and organizes the following documents into a separate section of the record: face sheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered

A) administrative data.
B) clinical data.
C) financial data.
D) miscellaneous data.

Question 67

Ms. RHIT is developing an audit tool to review records in preparation for The Joint Commission survey. Which of the following is a standard that should be included on the audit tool?

A) Each record needs to include a statistical summary sheet.
B) The attending physician must sign an attestation statement.
C) The record needs to document evidence of appropriate informed consent.
D) The discharge summary must be completed within 35 days of discharge.

Question 68

The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient weights on the day of admission as well as the day of discharge. This information can be located on the

A) discharge summary.
B) graphic record.
C) intake/output record.
D) nursing progress notes.

Question 69

Which of the following is not documented as a part of a consultation report?

A) Consulting physician's signature
B) Diagnosis and findings
C) Recommendations and opinions
D) Signature of requesting physician

Question 70

In which of the following cases would documentation of an interval history be acceptable?

A) newborn admitted four days after birth for dehydration who is treated with IV fluids
B) 17-year-old patient admitted for appendicitis who undergoes routine surgery during admission
C) 34-year-old woman readmitted for chest pain following delivery of a baby girl three days ago
D) 74-year-old readmitted for pneumonia seven days following discharge for this condition

Question 71

Review the following patient record entry, and determine in which report it would be documented.
$\begin{array}{|l|l|}\hline \text { Skin } & \text { No jaundice; reveals pale, cool, moist surface } \\\hline \text { Chest } & \text { Respirations normal } \\\hline \text { Lungs } & \text { Clear on inspection, percussion, and auscultation } \\\hline \text { Abdomen } & \text { No tenderness, guarding, or rigidity } \\\hline \text { Extremities } & \text { No significant findings } \\\hline \text { Genitalia } & \text { Normal } \\\hline \text { Rectal } & \text { Deferred } \\\hline\end{array}$

A) Chief complaint
B) History of present illness
C) Physical examination
D) Review of systems

Question 72

Nurse Smith believes that inpatient Tom Jones needs physical therapy because his gait is unsteady when she works him. Which of the following would occur?

A) Nurse Smith would schedule Tom to be seen by the hospital physical therapist.
B) Nurse Smith would begin bedside physical therapy for the patient.
C) Nurse Smith would change the nursing care plan to include physical therapy.
D) Nurse Smith would discuss her observations with Tom's attending physician.

Question 73

Dr. Cook records the following as part of a history and physical examination: "Patient presents with abdominal pain of seven days' duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out appendicitis vs. obstruction of colon." The diagnoses recorded are

A) admission diagnoses.
B) differential diagnoses.
C) primary diagnoses.
D) secondary diagnoses.

Question 74

Dr. Health sees Jack in her office to monitor his blood chemistry. She completes an examination and orders blood tests. Her medical assistant completes the venipuncture. Charges for these services would be recorded on a(n)

A) encounter form.
B) face sheet.
C) fee schedule.
D) superslip.

Question 75

Which of the following observations would be found in the physical examination report?

A) Has smoked two packs of cigarettes daily for past 30 years
B) Needs assistance to perform activities of daily living
C) Abdomen soft and tender with no rebound tenderness
D) Review of systems negative for hypertension and diabetes

Question 76

The major responsibility of a complete and accurate record rests with the:

A) attending physician.
B) director of HIM.
C) medical director.
D) medical staff committee.

Question 77

As Ms. RHIT assembles and analyzes a discharged obstetrical patient's record, she finds the forms listed below. Which should be pulled from the discharged patient's record? ​
Face sheet
Admission history and physical exam
Consents
Patient's property record
Insurance claim
Laboratory reports
Antepartum record (copy)
Labor and delivery record
Incident report
Postpartum record
​

A) A antepartum record (copy)
B) Antepartum record (copy), insurance claim, and incident report
C) Incident report and antepartum record (copy)
D) Incident report and insurance claim

Question 78

A patient's record contains the following order: "Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks." This is an example of a

A) discharge order.
B) routine order.
C) stop order.
D) transfer order.

Question 79

Dr. Smith enters the following information as part of a progress note: "2/3/YYYY. Patient complains of right upper abdominal pain of four days' duration." This information represents the

A) chief complaint.
B) history of present illness.
C) interval history.
D) physical examination.

Question 80

Dr. Balby writes the following note: “Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant.” This information would be documented as part of the

A) antepartum record.
B) labor and delivery record.
C) prenatal record.
D) postpartum record.