Which of the following represents documentation of the patients current and past health status quizlet?

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Terms in this set (30)

Which of the following is an example of clinical data?

- Admitting diagnosis
- Date and time of admission
- Insurance information
- Health record number

Admitting diagnosis

Which of the following contains the physician's findings based on an examination of the patient?

- Physical exam
- Discharge summary
- Medical history
- Patient instructions

Physical exam

When correcting erroneous information in a paper health record, which of the following is not appropriate?

- Print "error" above the entry.
- Enter the correction in chronological sequence.
- Add the reason for the change
- Use black pen to obliterate the entry.

Use black pen to obliterate the entry.

Documentation standards and guidelines are published by a variety of private and public organizations, including the:

- Joint Commission

- American Health Information Management Association

- National Committee for Quality Assurance

- All of the above

All of the above

In which setting may treatment records travel with the patient between treatment centers?

- Ambulatory care
- Behavioral healthcare
- Correctional facility care
- Long-term care

Correctional facility care

Patient history questionnaires are most often used in:

- Long-term care
- Rehabilitative care
- Home healthcare
- Ambulatory care

Ambulatory care

Which accrediting organization has instituted unannounced surveys and requires submission of annual performance reviews?

- Accreditation Association for Ambulatory Healthcare

- Commission on Accreditation of Rehabilitation Facilities

- American Osteopathic Association

- Joint Commission

Joint Commission

Which type of specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?

- Ambulatory care record
- Emergency care record
- Ambulatory surgery record
- Pediatric record

Emergency care record

What is the general name for Medicare standards impacting healthcare organizations?

- Conditions of Participation
- Regulations for Licensure
- Requirements for Service
- Terms of Accreditation

Conditions of Participation

Which of the following is an advantage of paper-based records?

- Easy to update
- Standardized familiar format
- Duplicates commonly maintained
- Resists damage

Standardized familiar format

Which of the following is not usually a component of acute care patient records?

- Medical history
- Nurse assessment
- Problem list
- Progress notes

Problem list

The attending physician is responsible for which of the following types of acute- care documentation?

- Consultation report
- Discharge summary
- Laboratory report
- Pathology report

Discharge summary

A nurse is responsible for which of the following types of acute care documentation?

- Operative report
- Medication record
- Radiology report
- Therapy assessment

Medication record

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?

- Home health
- Behavioral health
- End-stage renal disease
- Rehabilitative care

Home health

Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?

- Paper record
- Hybrid record
- Electronic record
- Problem-oriented record

Electronic record

Which of the following is not an example of a long-term care setting?

- Assisted living facilities
- Nursing homes
- Community mental health centers
- Subacute care organizations

Community mental health centers

An RAI/MDS and care plan are found in records of patients in:

- Home healthcare
- Long-term care
- Behavioral healthcare
- Rehabilitative care

Long-term care

In a medical history, which of the following is a detailed chronological description of the development of the patient's illness?

- Chief complaint
- Present illness
- Past medical history
- Review of systems

Present illness

Which type of patient care record includes documentation of a family bereavement period?

- Hospice record
- Home health record
- Long-term care record
- Ambulatory care record

Hospice record

Which of the following represents documentation of the patient's current and past health status?

- Physical exam
- Medical history
- Physician orders
- Patient consent

Medical history

Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?

- American Osteopathic Organization

- Commission on Accreditation of Rehabilitation Facilities

- Accreditation Association for Ambulatory Healthcare

- Joint Commission

Commission on Accreditation of Rehabilitation Facilities

The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the:

- Anesthesia report
- Progress notes
- Operative report
- Recovery room report

Operative report

Documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record?

- Correctional facility health record
- End-stage renal disease record
- Long-term care record
- Personal health record

Personal health record

Which of the following is an example of an advance directive?

- Living will
- Authorization to disclose information
- Notice of privacy practices
- Patient's bill of rights

Living will

What is the function of physician's orders?

- To provide a chronological summary of the patient's illness and treatment

- To document the patient's current and past health status

- To document the physician's instructions to other parties involved in providing care to a patient

- To document the provider's instructions for follow-up care given to the patient or patient's caregiver

To document the physician's instructions to other parties involved in providing care to a patient

What is the function of a consultation report?

- Provides a chronological summary of the patient's medical history and illness

- Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

- Concisely summarizes the patient's treatment and stay in the hospital.

- Documents the physician's instructions to other parties involved in providing care to a patient

Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

Which of the following organizations drafted more than 130 functional standards for electronic health records?

- Health Level Seven (HL7)

- International Standards Organization

- American Health Information Management Association

- National Library of Medicine

Health Level Seven (HL7)

"The patient indicates that she is dizzy, nauseous, and feels her throat tightening." This entry would be recorded in which section of a SOAP note?

- Subjective
- Objective
- Assessment
- Plan

Subjective

Which of the following represents the attending physician's assessment of the patient's current health status?

- Physical examination
- Medical history
- Progress notes
- Discharge summary

Physical examination

Which of the following is true of computer-based records?

- Is usually supported by all healthcare providers

- Can be accessed by multiple end users simultaneously

- Uses clear, consistent content standards

- Permits minimal risks to healthcare privacy and security

Can be accessed by multiple end users simultaneously

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