Deck 5: Healthcare Records

Question 1

Previous illnesses, operations, injuries, diseases, allergies, and immunizations are all part of the:

A) past medical history.
B) social history.
C) family history.
D) review of systems.
E) history of present illness.

Answer 1

past medical history.

Question 2

The word data refers to:

A) records of facts.
B) computer information.
C) patient information.
D) presentation of information.
E) All of the above

Answer 2

records of facts.

Question 3

All orders, including medications, lab tests, and diagnostic tests, must be:

A) dated.
B) signed.
C) verbally ordered.
D) ordered in person.
E) Both A and B

Answer 3

Both A and B

Question 4

Which of the following refers to the presentation of patient information in a useful form and the association of other relevant details with it?

A) Computer data
B) Health information
C) Patient data
D) Health data
E) Consumer information

Question 5

All of the following are examples of secondary health records EXCEPT:

A) master patient indexes.
B) reports from other providers.
C) health insurance claims.
D) aggregate data.
E) All of the above

Question 6

Radiology departments store images such as CT scans, PET scans, and MRIs on a Picture Archiving and Communication System.

Question 7

The acronym SOAP stands for:

A) subjective, objective, assessment, plan.
B) subjective, occupational, assessment, plan.
C) subjective, operative, ailments, plan.
D) subjective, objective, ailments, patient.
E) subjective, objective, assessment, patient.

Question 8

A patient history for an ambulatory visit includes:

A) review of systems.
B) family history.
C) history of present illness.
D) chief complaint.
E) All of the above

Question 9

Records that are created by abstracting and summarizing information from primary records are:

A) primary records.
B) secondary records.
C) compiled records.
D) research records.
E) summary records.

Question 10

Records gathered directly from the patient and his or her providers that document the patient's history and state of health are:

A) secondary records.
B) research records.
C) data records.
D) primary records.
E) original records.

Question 11

The patient health record is a legal document.

Question 12

Admission and discharge notes would be found in a chart from which of the following facilities?

A) Ambulatory care facility
B) Home care agency records
C) Acute care hospital records
D) Rehabilitation clinic records
E) Dental office records

Question 13

Information from health records is often used to track:

A) births.
B) exposure to hazardous materials.
C) child abuse.
D) communicable diseases.
E) All of the above

Question 14

Social reasons that are encouraging healthcare providers to move toward electronic health records include which of the following?

A) Patients are moving more often
B) Patients are changing physicians more often
C) Patients often see multiple physicians
D) The ability to share patient information is important for patient care
E) All of the above

Question 15

An inpatient admission requires a history and physical within ________ days prior to admission or 24 hours after admission.

A) 5
B)10
C) 14
D) 28
E) 30

Question 16

Practical reasons for healthcare providers to move to an electronic health record include all of the following statements EXCEPT:

A) paper records are easily accessed and shared.
B) paper charts must be copied or faxed.
C) handwritten charts can be illegible.
D) searching the contents of a paper chart requires manually opening it and looking through it.
E) paper charts must be transported from one office to another.

Question 17

The principle reason for a visit is the:

A) history of present illness.
B) review of systems.
C) chief complaint.
D) social history.
E) past medical history.

Question 18

Which of the following documents is NOT a consent form?

A) Consent to treatment
B) Medicare patient rights statement
C) Medical history
D) Advance directive
E) Assignment of benefits

Question 19

The paper patient demographic form is called a(n):

A) admission record.
B) face sheet.
C) data form.
D) history form.
E) patient information sheet.

Question 20

All of the following statements are true of the patient health record EXCEPT:

A) it is not used for billing and reimbursement.
B) it provides information about the patient's treatment.
C) it is the primary communication document for those who care for the patient.
D) medical bills will not be paid if the patient record does not contain necessary documentation.
E) it provides information about the patient's health history.

Question 21

Errors must never be obliterated.

Question 22

An attending physician's request for a consult is called a(n):

A) patient request.
B) medical request.
C) referral.
D) consultation.
E) None of the above

Question 23

Inpatient stays longer than 48 hours require a(n):

A) history and physical.
B) consultation.
C) discharge summary.
D) Both A and B
E) Both A and C

Question 24

Home health agencies use the OASIS standard to document data that is sent electronically to the state and CMS every ________ days.

A) 10
B) 14
C) 28
D) 60
E) 120

Question 25

Which of the following data sets are used in acute care hospitals and required by CMS?

A) Uniform Ambulatory Care Data Set
B) Uniform Clinical Data Set
C) Minimum Data Set
D) Outcome and Assessment Information Set
E) Uniform Hospital Discharge Data Set

Question 26

Errors in a paper health records should be corrected by FIRST:

A) erasing the error.
B) drawing two lines through the error.
C) drawing one line in ink through the error.
D) drawing an "x" over the error.
E) Any of the above are acceptable.

Question 27

The birth of a baby requires a document recording the birth to be signed and sent to the:

A) admission office.
B) parents.
C) attending physician.
D) state health department.
E) federal government.

Question 28

Which of the following would NOT be found on a discharge summary?

A) Summary of laboratory results
B) A brief history justifying the need for hospitalization
C) Family history
D) Patient condition at time of discharge
E) Principle and other diagnoses

Question 29

All of the following documentation guidelines have been developed by AHIMA EXCEPT:

A) the health record should be organized systematically.
B) only authorized individuals should be allowed to enter documentation in the health record.
C) all entries in the health record should not be permanent.
D) authors of entries should be clearly identified in the health record.
E) only approved abbreviations and symbols should be used in the health record.

Question 30

Data elements may require several fields.

Question 31

Health information professionals use which of the following to ensure quality patient records?

A) Data sets
B) Data elements
C) HIM policies
D) HIM procedures
E) All of the above

Question 32

A problem list is required by the Joint Commission on ambulatory charts.

Question 33

A discharge summary is required for infants born without complications.

Question 34

A physician updates a patient's home health certification/plan of care every ________ days.

A) 10
B) 14
C) 30
D) 60
E) 90

Question 35

A specialist that is asked to see a patient or review a case is a(n):

A) admitting physician.
B) consulting physician.
C) primary physician.
D) discharging physician.
E) referring physician.

Question 36

A(n) ________ is required in all cases of death.

A) social history
B) family history
C) discharge summary
D) review of care
E) autopsy

Question 37

A list of data elements collected for a particular purpose is:

A) a data set.
B) data information.
C) data fields.
D) a data list
E) None of the above

Question 38

Surgical procedures require which of the following?

A) Anesthesia records
B) Intraoperative records
C) Informed consent for the procedure
D) Postoperative progress note
E) All of the above

Question 39

An up-to-date list of both acute and chronic conditions affecting the patient's care is a(n):

A) history and physical.
B) admission list.
C) problem list.
D) review of systems.
E) problem set.

Question 40

All of the following are documented by nurses in an inpatient facility EXCEPT:

A) patient's social history.
B) administration of medications.
C) treatments ordered by the physician.
D) patient response to treatment.
E) insurance information.

Question 41

Obstacles when forming a RHIO include:

A) technical issues.
B) economic issues.
C) political issues.
D) All of the above
E) None of the above

Question 42

In 2004, the National Coordinator for Health Information Technology position was established by:

A) Bill Clinton.
B) George Bush, Jr.
C) Dick Cheney.
D) Dr. Richard Carmona.
E) George Bush, Sr.

Question 43

The acronym PHR stands for:

A) provider health record.
B) personal health record.
C) patient health record.
D) private heath record.
E) preventative health record.

Question 44

The ________ attempted to make patient records available to providers that were members of larger healthcare organizations.

A) electronic medical network
B) integrated delivery network
C) national health information network
D) patient information network
E) patient health record network

Question 45

Communication technology used to deliver medical care to a patient in another location is called:

A) remote clinical technology.
B) telemedicine.
C) rural healthcare technology.
D) telocare technology.
E) None of the above

Question 46

Which of the following is NOT an advantage of the PHR?

A) Patients enter the information themselves.
B) Patients can retrieve their own records.
C) The record can be retrieved using the Internet.
D) It can integrate information from many different providers.
E) It can integrate information about medications.

Question 47

The exchange of health information across medical practices and facilities owned by different entities for better patient well-being is encouraged by regional health information organizations.

Question 48

Which of the following statements is TRUE about teloradiology?

A) It transmits diagnostic images between two locations.
B) Transmitted images are read by a radiologist on the receiving end.
C) It may be used to obtain a second opinion.
D) Radiologists on the receiving end must be licensed by the state in which the images were sent from.
E) All of the above

Question 49

All of the following statements about E-visits are true EXCEPT:

A) the E-visit is kept separate from the patient chart.
B) E-visits can be handled by the "doctor on-call."
C) E-visits are not appropriate for new patients who have never been seen at the practice.
D) E-visits are used for non-urgent visits.
E) a clinician can prescribe medications during an E-visit.

Question 50

Who owns the patient health record?

A) The facility or practice
B) The patient
C) The federal government
D) The state
E) All of the above