Question 1

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.

Accepted Answer

The answer of Sam Smith, a social worker at Sunny...

Question 2

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?

Accepted Answer

Dr. Johns, as the resident who performed the examination and dictated the report, must sign it first. Dr. Blake, as the attending physician, must then countersign to verify and take responsibility for the resident's work.

Question 3

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

Accepted Answer

Falls in healthcare settings are documented on an incident report. This type of report is used to record any unexpected event that could or does result in harm to a patient, staff member, or visitor, including falls.

Question 4

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

Accepted Answer

CMS210 is the Home Care Certification and Plan of Care form used for Medicare patients.

Question 5

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.

Accepted Answer

Objective information in a SOAP note includes measurable, observable, and reproducible findings such as vital signs (blood pressure, temperature) and physical examination results (lung sounds, presence of nasal congestion), which are all mentioned in the scenario.

Question 6

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

Accepted Answer

The answer of Sally Jones analyzes patient records and identifies...

Question 7

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

Accepted Answer

Dr. Blake needs to sign the order within the time period specified by the facility's medical staff bylaws. This is a common requirement to ensure that verbal or telephone orders are properly authenticated by the prescribing physician within a specified timeframe, enhancing the accuracy and accountability of patient care orders.

Question 8

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

Accepted Answer

The answer of Sunny Valley Hospital uses auto-authentication for transcribed...

Question 9

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

Accepted Answer

ABC Insurance would deny payment for the specific $50.00 laboratory test that was billed but not documented in the record, not for all services provided.

Question 10

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

Accepted Answer

Pre- and postanesthesia evaluations are typically part of the surgical care record, as they are essential components of the anesthesia care process before and after surgery.

Question 11

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

Accepted Answer

The answer of The quality improvement committee wants to determine...

Question 12

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

Accepted Answer

Completing medical records consistently ensures that all healthcare providers have access to accurate and comprehensive patient information, which is essential for providing continuous and coordinated care.

Question 13

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

Accepted Answer

Sally Jones's role involves presenting information, which aligns with report generation, as it involves compiling and presenting data in a structured format.

Question 14

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

Accepted Answer

Reverse chronological date order means the most recent documents are placed at the front, which matches the physicians' request.

Question 15

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?

Accepted Answer

An audit trail is a record that shows who has accessed a computer system and what operations he or she has performed during a given period of time. It is useful for monitoring and analyzing the behavior of users, ensuring security and compliance, and in this case, tracking the number of times providers make corrections in patient documentation within an electronic health record system.

Question 16

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.
​

Accepted Answer

The answer of Mary Jones, a new employee at Sunny...

Question 17

The American Hospital Association recommends that patient records be retained for

Accepted Answer

The American Hospital Association recommends that patient records be retained for at least five years. This recommendation is made to ensure that hospitals maintain a comprehensive record of patient care for a sufficient period, which is crucial for legal, medical, and historical reasons.

Question 18

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

Accepted Answer

Jacket film allows for individual patient records to be stored separately after microfilming, which aligns with the HIM manager's decision for individual storage of each patient record post-microfilming.

Question 19

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

Accepted Answer

The information includes treatment for alcohol abuse, depression, and documentation of therapy and treatment, which are all related to behavioral health. Behavioral health information encompasses mental health, substance abuse, and more, which aligns with the details provided about Dan's medical history.

Question 20

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.

Accepted Answer

A signature legend is a tool used to match initials or signatures to the full name of the author, helping to identify who made specific entries in patient records.

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