Question 1

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

Accepted Answer

The Uniform Hospital Discharge Data Set (UHDDS) is the correct term for the minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs.

Question 2

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

Accepted Answer

Suspension of physician privileges is an action that could be taken by the hospital in response to Dr. Smith's 10 delinquent patient records.

Question 3

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

Accepted Answer

Autopsies are typically performed to determine the cause of death in cases where it is unexpected, such as in sudden infant deaths, pediatric deaths, or deaths that occur under unusual circumstances like in an operating room. For cancer patients, the cause of death is usually known, and an autopsy might not be necessary unless there are unusual circumstances surrounding the death.

Question 4

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

Accepted Answer

The name, address, and phone number of the third-party payer are related to billing and payment, which falls under financial data.

Question 5

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

Accepted Answer

A transfer summary is used when a patient is moved to a different level of care within the same hospital, detailing the reason for transfer, the care received prior to transfer, and the patient's current condition and plan of care.

Question 6

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

Accepted Answer

A living will is a document that specifies a patient's wishes regarding life-sustaining treatments in situations where they may be unable to communicate their decisions.

Question 7

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

Accepted Answer

Comorbidity refers to an additional condition that exists alongside the primary condition for which the patient is being treated. In this case, the uncontrolled diabetes is a comorbidity because it is an additional condition that exists alongside the congestive heart failure and hypertension but is not the reason for the hospital admission.

Question 8

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

Accepted Answer

The Joint Commission requires that a discharge summary be completed within 30 days of discharge to ensure continuity of care and proper documentation of the patient's hospitalization details.

Question 9

Progress notes should be written

Accepted Answer

Progress notes should be written as the patient's condition warrants to ensure accurate and up-to-date documentation of the patient's status and care.

Question 10

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

Accepted Answer

Informed consent is the process through which a healthcare provider educates a patient about the risks, benefits, and alternatives of a proposed procedure or intervention, allowing the patient to make a knowledgeable decision about their care.

Question 11

Which is an example of clinical data?

Accepted Answer

Anesthesiology reports are examples of clinical data because they contain detailed medical information about the anesthesia administered during a patient's surgery, including drugs used, dosages, patient responses, and any complications. This data is directly related to patient care and treatment.

Question 12

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

Accepted Answer

The correct place to document a patient's personal belongings, such as a diamond ring, upon admission to a hospital is on the patient property form. This ensures the items are accounted for and can be returned to the patient upon discharge.

Question 13

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

Accepted Answer

The statement "When I walk up stairs, I have difficulty breathing" directly addresses the primary reason for Bob Lot's visit to Dr. Jones, making it his chief complaint. This term is used to describe the main issue or symptom that brings a patient to seek medical attention.

Question 14

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

Accepted Answer

Information concerning the mother's condition after delivery is documented in the postpartum record. This record focuses on the mother's health and recovery following childbirth.

Question 15

Which statement regarding the patient record is true?

Accepted Answer

All entries in a patient record must be legible and complete to ensure accurate communication among healthcare providers and for legal documentation.

Question 16

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

Accepted Answer

Birth certificate information is typically submitted to the state departments of health or offices of vital statistics within 10 days of birth. These entities are responsible for recording and maintaining vital records, including birth certificates.

Question 17

An APGAR score is documented in the

Accepted Answer

The APGAR score is a quick test performed on a newborn at 1 and 5 minutes after birth. The score assesses the baby's heart rate, respiration, muscle tone, reflex response, and color. This score is documented in the newborn record to evaluate the physical condition of the newborn and determine any immediate need for extra medical or emergency care.

Question 18

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

Accepted Answer

Every report and page/screen in a patient record must include the patient name and an identification number to ensure accurate identification and tracking of patient information.

Question 19

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

Accepted Answer

A comorbidity is a preexisting condition that affects the treatment and length of stay of a patient's current illness or condition. It is distinct from the principal diagnosis (the main reason for the hospital stay), a complication (a new problem that arises during treatment), and the chief complaint (the primary symptom or problem that brought the patient to seek medical attention).

Question 20

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

Accepted Answer

The provisional diagnosis is the initial diagnosis given based on the current signs and symptoms, which guides the initial treatment plan.

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