Deck 4: The Patient Record: Hospital, Physician Office, and Alternate Care Settings

Question 1

Since the early 1980s, the provision of outpatient services has decreased.

Answer 1

False

Question 2

The legibility of patient record entries impacts patient care.

Answer 2

True

Question 3

A consultation report, history and physical exam, and operative report are all types of administrative data.

Answer 3

False

Question 4

The ordering physician is not required to countersign a telephone order documented by a nurse.

Question 5

Fax signatures are not accepted by facilities.

Question 6

The primary purpose of the patient record is to provide continuity of care.

Question 7

The medical record is the property of the provider.

Question 8

Administrative data include demographic, socioeconomic, and financial information.

Question 9

Inpatient record creation may begin prior to admission, when preadmission testing is performed.

Question 10

Demographic data is a type of clinical data that identifies a patient's medical condition.

Question 11

Source-oriented records consist of a database, problem list, and initial plan.

Question 12

A patient record serves as a business record for the patient encounter and contains administrative and clinical data.

Question 13

The Joint Commission requires that patient records be completed within 20 days after a patient is discharged.

Question 14

Incident reports should be filed in the patient record.

Question 15

At the time of admission, the patient or patient representative often signs an admission consent form to consent to treatment.

Question 16

Health care providers are responsible for documenting care and treatment to prove that patient care was provided.

Question 17

When an individual is admitted as a hospital inpatient, past records are frequently retrieved to provide for continuity of care.

Question 18

A signature legend identifies the author of a record entry by full signature when initials are used in the patient record.

Question 19

Most facilities organize the patient record according to reverse chronological date order during inpatient hospitalization.

Question 20

Demographic data are documented on the face sheet of a manual patient record.

Question 21

The medical record is the property of the

A) patient.
B) provider.
C) government.
D) insurance company.

Question 22

The Joint Commission requires patient records to be completed ____ days after a patient is discharged.

A) 10
B) 15
C) 25
D) 30

Question 23

An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the

A) preadmission testing.
B) primary provider.
C) principal procedure.
D) provisional diagnosis.

Question 24

When a facility closes, it is the responsibility of the closing facility to ensure that records are handled according to federal and state statutes.

Question 25

An admissions clerk enters "right lower abdominal pain" as the admission diagnosis on the face sheet. This information is known as

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

Question 26

Medical transcription involves coding of diagnostic information.

Question 27

Medicare Conditions of Participation require hospitals to retain medical records for a period of no less than five years.

Question 28

Between 1996 and 2006, the number of ambulatory care visits in the United States has

A) decreased.
B) increased.
C) remained the same.
D) stayed constant until 1999.

Question 29

Initials of care providers are typically used to authenticate entries on

A) admission assessments and histories.
B) discharge summaries.
C) flow sheets and medication records.
D) operative reports.

Question 30

Tom Smith, a patient at Sunny View Hospital, fell out of his bed during his inpatient admission. An incident report was completed at the time of the fall. Smith is suing the hospital because he feels that the nurses were negligent when caring for him. The following actions were taken by the facility. Determine which of these actions should not have occurred. ​
A-The incident report was filed in the risk management office.
B-A note was entered in the patient, record stating that an incident report was completed.
C-A copy of the incident report was filed in the patient's record.
D-Defense attorneys for the health care facility reviewed the incident report to prepare for the case.
​

A) A and B
B) A and C
C) B and C
D) B and D

Question 31

A form of authentication by an individual in addition to the signature by the original author is known as a(n)

A) auto-authentication.
B) countersignature.
C) fax signature.
D) rubber stamp signature.

Question 32

An initial plan describes the actions that will be taken to evaluate, treat, and educate the patient about his or her current condition.

Question 33

Which of the following record formats links all documentation to a specific problem?

A) Integrated
B) Paper-based
C) Problem-oriented
D) Source-oriented

Question 34

Computer systems have changed the functions and role of health information professionals.

Question 35

An inpatient record is typically between ____ in length.

A) 30 and 50 pages
B) 40 and 60 pages
C) 60 and 100 pages
D) 125 and 175 pages

Question 36

Which filing order saves time in processing discharged records?

A) Chronological order.
B) Date order.
C) Reverse chronological order.
D) Universal chart order.

Question 37

Sunny Valley Hospital uses the SOAP structure to document patient information. Observations about the patient would be documented in the ____ section of the progress note.

A) subjective
B) objective
C) assessment
D) plan

Question 38

Which is an example of clinical data?

A) Date of birth
B) Diagnosis
C) Patient name
D) Social Security number

Question 39

Medical transcriptionists are credentialed by AHDI.

Question 40

The Joint Commission requires that the history and physical examination be documented in the patient record within ____ of inpatient admission.

A) 7 hours
B) 24 hours
C) 48 hours
D) 72 hours

Question 41

Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient's record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the ____ data recorded in the record.

A) clinical
B) demographic
C) financial
D) socioeconomic

Question 42

Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie's attending physician. Who must sign the history and physical?

A) Dr. Blake only must sign.
B) Dr. Johns only must sign.
C) Dr. Johns must sign the report first and then Dr. Blake must countersign.
D) Dr. Blake must sign the report first and then Dr. Johns must countersign.

Question 43

Tom Black falls while transferring from his bed to a wheelchair. This would be documented on a(n)

A) compliance report.
B) fall report.
C) incident report.
D) safety report.

Question 44

A home care record generated for a Medicare Patient contains a Home Care Certification and Plan of Care also known as form

A) CMS100
B) CMS1500
C) CMS210
D) CMS485

Question 45

Dr. Jones records the following information in the ____ section of a patient's SOAP note: BP is 120/74. Temperature is 100°F. Upon examination, lungs are clear but patient has nasal congestion.

A) assessment
B) objective
C) plan
D) subjective

Question 46

Sally Jones analyzes patient records and identifies several records without final diagnoses and procedures recorded on the face sheet. The type of analysis she performed is

A) deficiency.
B) qualitative.
C) quantitative.
D) statistical.

Question 47

Nurse Jones takes a telephone order from Dr. Blake. Determine which of the following should occur.

A) The order needs to be signed by the house staff.
B) Dr. Blake needs to sign the order within the time period specified by the facility's medical staff bylaws.
C) Dr. Blake only needs to sign the order if the order is altered.
D) The order does not need to be signed by Dr. Blake if it was signed by Nurse Jones.

Question 48

Sunny Valley Hospital uses auto-authentication for transcribed records. Which of the following would apply?

A) Physicians enter a unique identifier immediately following transcription.
B) Physicians enter a unique identifier before a report is transcribed.
C) Physicians enter a unique identifier after they proofread a report.
D) Physicians sign the report after the report is placed on the chart.

Question 49

ABC Insurance has requested a copy of Sally Smith's inpatient record to reconcile the documentation in the record with a claim submitted by Sunny View Hospital for $200.00 of laboratory services and $325.00 of radiology services. Upon review of the record, ABC Insurance has determined that the laboratory report does not contain documentation for a laboratory test billed at $50.00. ABC Insurance Company would deny payment for

A) all of the charges.
B) $50.00.
C) $200.00.
D) $325.00.

Question 50

Pre- and postanesthesia evaluations would be found in a(n) ____ record.

A) ambulatory care
B) behavioral health care
C) long-term care
D) surgical care

Question 51

The quality improvement committee wants to determine the number of patients admitted with a fever. The quickest way to locate this information would be to review the

A) admission history and physicals.
B) face sheets.
C) input/output records.
D) nursing assessments.

Question 52

The primary reason for completing medical records in a fashion consistent with medical staff policies and procedures is to

A) document risk management activities.
B) comply with accreditation requirements.
C) generate revenue from third-party payers.
D) provide continuity of care to patients.

Question 53

Sally Jones is responsible for analyzing, organizing, and presenting information based on patient records. This is a function of:

A) data capture
B) information capture
C) information generation
D) report generation

Question 54

The physicians at Sunny Valley Hospital have requested that all progress notes be organized with the most current progress note filed first, a type of filing order known as

A) chronological date order.
B) date order.
C) reverse chronological date order.
D) reverse date order.

Question 55

Sunny Valley Hospital has an electronic health record system. The health information management (HIM) department has been asked by the quality management department to monitor the number of times that providers make corrections in patient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions?

A) Audit trail
B) Independent database files
C) Digital signature log
D) Public key cryptography

Question 56

Mary Jones, a new employee at Sunny Valley Hospital, is being trained in concurrent analysis. She notices that records she reviews are organized as follows: ​
1/2/XX Nursing assessment
1/2/XX Admission history and physical
1/2/XX CBC report
1/3/XX Chest X-ray
1/3/XX Nursing progress note
1/3/XX Physician's progress note
This is considered a(n) ____ format.
​

A) integrated
B) problem-oriented
C) sectioned
D) source-oriented

Question 57

The American Hospital Association recommends that patient records be retained for

A) two years.
B) three years.
C) four years.
D) five years.

Question 58

The HIM manager at Sunny View Hospital has decided that all records over two years old will be microfilmed, and that each patient record should be stored individually after microfilming. This can be accomplished by using

A) cartridge film.
B) jacket film.
C) reel film.
D) roll film.

Question 59

Dan Smith has recently moved to a new town. He calls Dr. Jones's office to make an appointment for an annual history and physical. It is the policy of Dr. Jones's office to have all new patients request information from their previous health care providers and forward copies to the office prior to their first visit. Dr. Jones reviews Dan's medical information, which includes treatment for alcohol abuse, depression, and documentation of therapy and treatment. This information would most accurately be referred to as

A) ambulatory care information.
B) behavioral health information.
C) case conference information.
D) social work information.

Question 60

Ms. Smith analyzes patient records for deficiencies and determines that there are entries that have been authenticated using initials. She needs to identify the author of these entries to clarify information. She should reference the ____ to determine the full name of the author of the entries.

A) authentication legend
B) authentication log
C) signature legend
D) signature log

Question 61

Each facility should maintain a(n) _________________________ that includes all medical staff approved abbreviations and symbols that can be documented in patient records.

Question 62

The abbreviation URI means

A) upper region.
B) upper region incision.
C) upper respiratory infusion.
D) upper respiratory infection.

Question 63

Operative reports, laboratory reports, and nursing intake/output records are types of ____________________.

Question 64

A patient's name, Social Security number, and date of birth are types of ____________________ data.

Question 65

The process of recording representations of human thought, perceptions, or actions in documenting patient care is known as _________________________.

Question 66

To calculate the delinquent record rate, divide the total number of delinquent records by the

A) total number of admissions in the period.
B) total number of discharges in the period.
C) length of stay for the period.
D) total number of admissions and then add the total number of discharges.

Question 67

All entries made in a patient's record must be ____________________, which means that the entry is signed by the author.

Question 68

AHIMA recommends that anyone who documents inpatient records be trained and follow the organization's standards and policies for ____________________.

Question 69

The abbreviation q.h. means

A) every half hour.
B) every hour.
C) every day.
D) every four hours.

Question 70

When signing a patient record entry, the author should minimally sign with the first initial, last name, and ____________________ or discipline.

Question 71

A generic term that refers to the various methods by which an electronic document can be authenticated is known as a(n) _________________________.

Question 72

The hospital outpatient record, also known as the _____________________, documents services received by a patient who has not been admitted to the hospital overnight and receives lab tests, ambulatory surgery, and so on.

Question 73

The patient record serves as a(n) ____________________document and as a business record.

Question 74

The use of signature stamps should be specified in the

A) administrative policies.
B) hospital bylaws.
C) medical staff bylaws.
D) nursing policies.

Question 75

A verbal order from a physician taken over the telephone by a qualified professional is known as a(n) ____________________.

Question 76

The Joint Commission states that the purpose of the patient record is to identify the patient and to support and justify the patient's ____________________, care, treatment, and services.

Question 77

The abbreviation NPO means

A) no personal orders.
B) not previously ordered.
C) nothing by mouth.
D) nothing abnormal found.

Question 78

Records maintained by alternate care settings vary because of the types of services delivered, _________________________, and state and federal regulations.

Question 79

Demographic, socioeconomic, and financial information are all types of _________________________.

Question 80

To determine the ____________________, divide the total number of delinquent records by the number of discharges in the period.