Question 1

Health information personnel with the title of ____________________ assign ICD-10-CM/ICD-10-PCS and/or CPT/HCPCS codes to all diagnoses and procedures.

Accepted Answer

The answer of Health information personnel with the title of...

Question 2

Additional diagnoses that describe conditions that arise after the beginning of the hospital observation and treatment are called ____________________.

Accepted Answer

The answer of Additional diagnoses that describe conditions that arise...

Question 3

The hospital record that documents diagnostic, therapeutic, and rehabilitation services of outpatients is the

Accepted Answer

The ambulatory record is specifically designed to document the care provided to patients who are treated on an outpatient basis, including diagnostic, therapeutic, and rehabilitation services.

Question 4

Molly Mapes was admitted to Sunny Valley Hospital on January 22 (this year) for pneumonia. The history and physical examination (H&P) was placed on the record January 24 (this year). Which of the following statements is true, based on Joint Commission standards?

Accepted Answer

The Joint Commission standards require that the history and physical examination (H&P) be completed and placed in the patient's record within 24 hours of admission.

Question 5

The minimum core data set collected on individual hospital discharges for the Medicare and Medicaid programs is the ________________________________________.

Accepted Answer

The answer of The minimum core data set collected on...

Question 6

A form that is signed by the patient to document that the patient has been notified of his or her right to have an advance directive is called a(n) ___________________________________.

Accepted Answer

The answer of A form that is signed by the...

Question 7

Which of the following documents that the patient acknowledges the nature of treatment, risk, and complications of care?

Accepted Answer

Consent forms are used to ensure that a patient has been informed about the nature of their treatment, including any risks and potential complications, and agrees to proceed with the treatment. This process is known as informed consent.

Question 8

Dr. Smith wants to implement a new form to record postoperative complications. This should be reviewed to be approved for use in the medical record by the

Accepted Answer

The forms committee is responsible for reviewing and approving new forms for use in the medical record to ensure they meet the hospital's standards and requirements.

Question 9

The death certificate is signed by a ____________________ and is usually filed within five days.

Accepted Answer

The answer of The death certificate is signed by a...

Question 10

The discharge summary documents the patient's hospitalization, the reason for hospitalization, course of treatment, and ______________________________.

Accepted Answer

The answer of The discharge summary documents the patient's hospitalization,...

Question 11

Which of the following is documented on the physical examination?

Accepted Answer

The physical examination documents observable or measurable facts about the patient's health, such as "Patient's lungs are congested." This statement reflects a direct observation made by the healthcare provider during the physical examination.

Question 12

Which of the following would not be documented on a medication administration record?

Accepted Answer

The medication administration record (MAR) is used to document medications that are administered to a patient, including the medication given, dosage, and the nurse or healthcare professional who administered the medication. A provisional diagnosis is not documented on the MAR; it would be found in the patient's medical record or chart.

Question 13

Patient identification information can be imprinted on forms by using a(n) ____________________.

Accepted Answer

The answer of Patient identification information can be imprinted on...

Question 14

Ms. RHIT is analyzing and assembling a patient's record and notices that a copy of a history and physical from the attending physician's office was used in the record instead of an inpatient history and physical. The office H&P was completed on January 2 (this year), and the patient was admitted to the hospital on January 5 (this year); the office H&P was placed on the record at the time of admission. According to Medicare CoP regulations, the office H&P is

Accepted Answer

According to Medicare Conditions of Participation (CoP) regulations, an H&P (History and Physical) that was completed no more than seven days prior to admission can be used for the patient's current admission, provided it is placed in the record and there is documentation that the patient's condition has not changed. In this scenario, the office H&P completed on January 2 and the patient's admission on January 5 falls within this seven-day window, making it acceptable.

Question 15

The process of advising a patient about treatment options, reason for surgery, possible complications, alternative treatment options, and risks is called _________________________.

Accepted Answer

The answer of The process of advising a patient about...

Question 16

Additional conditions for which the patient receives treatment or which impact inpatient care are called _________________________.

Accepted Answer

The answer of Additional conditions for which the patient receives...

Question 17

An inventory of body systems to reveal subjective symptoms stated by the patient is called the ____________________.

Accepted Answer

The answer of An inventory of body systems to reveal...

Question 18

At the time of admission, the patient is usually asked to sign a consent to admission, also called the ______________________________, which is a generalized consent that documents a patient's consent to receive treatment.

Accepted Answer

The answer of At the time of admission, the patient...

Question 19

A patient was admitted with chronic obstructive pulmonary disease (COPD) on April 15 (this year). The patient has an exacerbation of COPD and was readmitted on June 1 (this year). The physician needs to document a(n)

Accepted Answer

The answer of A patient was admitted with chronic obstructive...

Question 20

Birth certificates document infant and parent demographic information, parents' occupation, education, ethnicity, race, pregnancy information, and _____________________________________________.

Accepted Answer

The answer of Birth certificates document infant and parent demographic...

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