Question 1

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

Accepted Answer

Since the early 1980s, the provision of outpatient services has actually increased, largely due to advancements in medical technology, changes in payment and insurance structures, and efforts to reduce healthcare costs by shifting care away from more expensive inpatient settings.

Question 2

The legibility of patient record entries impacts patient care.

Accepted Answer

Legible patient record entries are crucial for ensuring accurate communication among healthcare providers, which directly impacts the quality and safety of patient care.

Question 3

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

Accepted Answer

These are examples of clinical data, as they directly relate to the patient's health and medical treatments. Administrative data typically includes demographic information, insurance details, and billing records.

Question 4

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

Accepted Answer

The ordering physician is typically required to countersign a telephone order documented by a nurse to verify and formally approve the order, ensuring it aligns with the patient's care plan and complies with healthcare regulations and facility policies.

Question 5

Fax signatures are not accepted by facilities.

Accepted Answer

Many facilities accept fax signatures for various documents as they are considered legally binding in many jurisdictions, provided they meet certain criteria for authenticity and integrity.

Question 6

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

Accepted Answer

The primary purpose of the patient record is to document the history, diagnosis, treatment, and care of a patient over time, ensuring continuity of care among healthcare providers.

Question 7

The medical record is the property of the provider.

Accepted Answer

The medical record is legally considered the property of the provider or the facility that created it, although the patient has the right to access the information contained within it.

Question 8

Administrative data include demographic, socioeconomic, and financial information.

Accepted Answer

Administrative data often encompass demographic (e.g., age, gender), socioeconomic (e.g., income, employment status), and financial information (e.g., transactions, account balances) as they are collected in the administration and operation of service programs or activities.

Question 9

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

Accepted Answer

Preadmission testing and information gathering are part of the inpatient record creation process, allowing healthcare providers to prepare for the patient's admission and treatment.

Question 10

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

Accepted Answer

Demographic data refers to general information about a person such as age, gender, ethnicity, and location, rather than specific medical conditions.

Question 11

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

Accepted Answer

Source-oriented records are organized by the source of the information, such as by healthcare provider or department, rather than by 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.

Accepted Answer

A patient record documents the healthcare services provided to a patient and includes both administrative data (such as patient demographics and billing information) and clinical data (such as medical history, diagnoses, treatment plans, and progress notes), serving as a comprehensive business record for each patient encounter.

Question 13

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

Accepted Answer

The Joint Commission requires that hospitals have a policy specifying the time frame for the completion of medical records, but it does not mandate a specific 20-day period. The actual time frame can vary by institution, but it is typically expected that records be completed promptly, often within 30 days.

Question 14

Incident reports should be filed in the patient record.

Accepted Answer

Incident reports are internal documents used for risk management and quality improvement purposes, not part of the patient's medical record.

Question 15

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

Accepted Answer

The admission consent form is a standard procedure in healthcare settings, allowing healthcare providers to perform necessary treatments and procedures as part of the patient's care.

Question 16

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

Accepted Answer

Health care providers must document care and treatment to ensure a record of what was provided, to communicate with other healthcare professionals, and to meet legal, regulatory, and quality standards.

Question 17

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

Accepted Answer

Past records are retrieved to ensure continuity of care by providing healthcare professionals with comprehensive information about the patient's medical history, previous treatments, and any ongoing health issues.

Question 18

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

Accepted Answer

A signature legend is used to link the initials or electronic signature used in patient records to the full name and credentials of the author, ensuring clear identification of who made each entry.

Question 19

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

Accepted Answer

In most facilities, the patient record during inpatient hospitalization is organized in reverse chronological order, meaning the most recent documents are placed at the front of the record for quick access to the latest information.

Question 20

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

Accepted Answer

The face sheet of a manual patient record typically includes demographic data such as the patient's name, address, date of birth, insurance information, and possibly next of kin, which are essential for patient identification and administrative purposes.

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