Assignment 2 Flashcards
True/False: A patient record serves as a business record for a patient encounter and contains clinical and demographic data
True
True/False: The medical record is the property of the provider
True
True/False: Administrative data includes demographic, socio-economic, and financial information
True
True/False: A consultation report, history and physical exam, and operative reports are all types of administrative data
False
True/False: The legibility of patient care record entries impacts patient care
True
True/False: Inpatient record creation may begin prior to admission when preadmission testing is performed
True
True/False: Most medical facilities organize the patient record according to reverse chronological order during inpatient hospitalization
True
True/False: Clinical data includes all patient medical information
True
True/False: Source oriented records consist of a database, problem list and initial plan and progress notes
False
True/False: A potentially compensable event is an accident or medical error that results in personal injury or loss of property
True
True/False: The electronic health record facilitates the creation of a longitudinal patient record
True
True/False: Patients do not have the right to access or review contents of their record
False
True/False: Continuity of care includes documentation of patient care servcices so that others that treat the patient have a source of information on which to provide additional care and treatment
True
True/False: A living will is a written document that informs a health care provider of a patient’s desires regarding life sustaining treatment
True
True/False: A delinquent record can result in suspension of a physician’s medical staff privileges
True
True/False: The history of the present illness is the patient’s description of his current medical condition in his own words
True
True/False: Integrated progress notes are documented by physicians, nurses, therapists, and other professionals in the same section of the patient record
True
True/False: A physician’s orders can be considered a “prescription” for care
True
True/False:A preoperative note is a progress note documented by the surgeon prior to surgery
True
True/False: EKG reports include a graphic printout of measurements of the electrical activity of the brain
False
True/False: The appearance of an outpatient to a hospital department to receive an ordered service, test or procedure is called an encounter
False
True/False: The role of a forms committee is to review all proposed forms to be used in the patient record
True
True/False: An autopsy must be authorized by the deceased’s next of kin, except when it is a coroner’s case
True
True/False: The patient history documents the patient’s chief complaint, history of the present illness, past/family/social history and review of systems
True
True/False: Electronic Health Records will improve care and reduce medical mistakes and costs
True
True/False: The use of a serial numbering system does not need computer software to track the assignment of patient numbers
True
True/False: In a unit numbering system, each time a patient is registered, a new patient number is assigned
False
True/False: A unit numbering system requires the retrieval of a patient’s record from multiple locations in the filing system when previous records are requested by a physician
False
True/False: Terminal digit numbers are usually written with a hyphen separating each part of the number
True
True/False: Patients have the right to have their record amended if they disagree with its content, or have a letter which clarifies their view attached to the record
True
True/False: An assisted living facility is a combination of housing and supportive services
True
True/False: Color-coding allows misfiles to be easily identified
True
True/False: Chart tracking systems help to control the file area and facilitate accurate tracking
True
True/False: A patient monitoring system includes systems that collect demographic information
False
True/False: Births, deaths, fetal deaths, marriages and divorces are exmples of vital statistics
True
True/False: In consecutive numeric filing, records are filed in chronological order according to the patient’s birth date
False
True/False: A summary of a set of data using charts graphs and tables is referred to as descriptive statistics
True
Which is an example of clinical data? a, date of birth b, diagnosis c. patient name d. social security number
b. diagnosis
An admission clerk enters “right lower abdominal pain” as the admission diagnosis on the face sheet. This information is known as
a. administrative data
b. clinical data
c. demographic data
d. financial data
b. clinical data
An inpatient record is typically between _____ in length
a. 30 and 50 pages
b. 40 and 60 pages
c. 60 and 100 pages
d. 125 and 175 pages
c. 60 and 100 pages
Since the early 1980’s, the number of outpatients treated by hospitals has
a. decreased
b. increased
c. remained the same
d. stayed constant
b. increased
If the order of a patient record reads like a diary, the forms are in
a. chronological date order
b. reverse chronological order
c. discharged record order
d. integrated date order
a. chronological date order
A form of authentication by an individual in addition to the signature by the original author is known as a(n)
a. auto authentication
b. countersignature
c. fax signature
d. rubber stamp signature
b. countersignature
When Janey Smith, a health record technician, reviews a patient chart and looks for items that are incomplete or incorrect, she is doing a _____ on a chart
a. record assembly
b. qualitative analysis
c. quantitative analysis
d. concurrent analysis
b. qualitative analysis
An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the
a. preadmission testing
b. primary provider
c. principal procedure
d. provisional diagnosis
d. provisional diagnosis
True/False: Patient records are filed in one location in the filing system when a unit or serial unit is used
True
Which filing order saves time in processing discharged records?
a. chronological order
b. date order
c. reverse chronological order
d. universal chart order
d. universal chart order
Tom Smith, a patient at Sunny View Hospital, fell out of bed during his inpatient admission. At the time of the fall an incident report was completed. He is now suing the hospital because he feels that the nurses were negligent when caring for him. The following actions were taken by the facility. Determine which of these actions should NOT have occurred
A. The incident report was filed in the risk management office
B. A note was entered in the patient record stating that an incident report was completed
C. A copy of the incident report was filed in the patient’s record
D. Defense Attornies for the health care facility reviewed the incident report to prepare for the case
a. A and B
b. A and C
c. B and C
d. B and D
c. B and C
Disadvantages of automated record systems include all EXCEPT which of the following
a. increased start-up costs
b. difficulty abstracting patient information
c. need for technical staff to maintain system
d. time consuming staff training
b. difficulty abstracting patient information
A group of characters forms a(n)
a. data form
b. field
c. information field
d. paragraph
b. field
Sunny Valley Hospital has an electronic health record system. The HIM department has been asked by the quality management department to monitor the number of times that providers make corrections to inpatient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions?
a. audit trail
b. independent database files
c. digital signature log
d. public key cryptography
a. audit trail
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 ehtnicity of the patient. This information would be part of the _____ data recorded in the record
a. clinical
b. epidemiological
c. financial
d. socioeconomic
c. socioeconomic
Dan Smith has recently moved to a new town and he calls Dr. Jones’ office to make an appointment for an annual history and physical. It is the policy of Dr. Jones’ office to have all new patients request information from their previous health care providers and forward copies to his office prior to their first treatment. Dr. Jones reviews Dan’s medical information that includes ANXIETY, depression, and documentation of therapy and treatment. This information would most accurately be referred to as:
a. ambulatory care information
b. behavioral health information
c. case conference information
d. social work information
b. behavioral health information
Pre- and post-anesthesia evaluations would be found in a(n) _______ record
a. ambulatory care
b. behavioral health care
c. long term care
d. surgical care
d. surgical care
When a (PCE) potentially comensable event occurs the report should be filed in
a. the health record
b. the health record manager’s office
c. risk manager’s office
d. privacy officer’s office
c. risk manager’s office
Steve Blue fell while he was transferred from his bed to a wheelchair. This would be documented on a(n)
a. compliance report
b. fall report
c. incident report
d. safety report
c. incident report
The third set of digits in this Terminal digit number (02 08 41) is considered to be the
a. terminal digit
b. primary
c. secondary
d. tertiary
b. primary
The primary reason for completing medical records in a fashion consistent with medical staff policies and procedures is to
a. document risk management activities
b. comply with accreditation requirements
c. generate revenue from third party payers
d. provide continuity of care to patients
d. provide continuity of care to patients
Sally Jones is responsible for analyzing, organizing and presenting information based on patient records. This is a function of
a. data capture
b. information capture
c. information generation
d. report generation
d. report generation
Tom Jones performs analysis of patient records and had identified several records without final diagnosis and procedures recorded on the face sheet. The type of analysis performed is
a. deficiency
b. qualitative
c. quantitative
d. statistical
b. qualitative
A collection of related fields is called a
a. character set
b. field
c. record
d. information set
c. record
Which of the following observations would be found in the physical examination report?
a. has smoked two packs of cigarettes daily for the past 30 years
b. needs assistance to perform activities of daily living
c. abdomen soft and tender with no rebounding tenderness
d. review of systems negative for hydration and diabetes
c. abdomen soft and tender with no rebounding tenderness
The physicians at Sunny Valley Hospital have requested that all progress notes be organized with the most current progress note filed first. This type of filing is known as
a. chronological date order
b. date order
c. reverse chronological date order
d. reverse date order
c. reverse chronological date order
At times a physician may have to document a change in one of their previous reports to clarify a statement made previously or to enter a late entry. This is known as a(n)
a. correction report
b. checklist
c. Addendum
d. audit report
c. Addendum
Automated chart completion managment software can assist health information departments in managing retrospective analysis by discharging patient records by generating all of these options except:
a. credit reports
b. suspension letters
c. customized reports
d. deficiency reports
a. credit reports
Ada Nosic is using an electronic health record system that collects and monitors a patient’s vital signs. This is a
a. patient clinical system
b. patient monitoring system
c. vital signs data system
d. vital signs information system
b. patient monitoring system
Which statement regarding the patient record is true
a. all entries must be legible and complete
b. an alias cannot be used in a patient record
c. only the front page of a two page document must contain patient identification
d. the author of each entry does not have to sign the note if another supervising professional has signed it
a. all entries must be legible and complete
The diagnosis that documents the condition or disease for which the patient is seeking treatment is the
a. discharge diagnosis
b. final diagnosis
c. provisional diagnosis
d. preoperative diagnosis
c. provisional diagnosis
Pre-existing conditions that cause an increase in the patient’s length of stay by at least one day in 75% of the cases is known as a(n)
a. chief complaint
b. complication
c. comorbidity
d. principal diagnosis
c. comorbidity
Every report and every page/screen in a manual or computerized patient record must include
a. medical record number and date of birth
b. patient name and address
c. medical record number and social security/insurance number
d. patient name and medical record number or date of birth
d. patient name and medical record number or date of birth
A patient is admitted for congestive heart failure and hypertension. During the admission the patient is also treated for uncontrolled diabetes. The uncrontrolled diabetes is a
a. complication
b. comorbidity
c. principal condition
d. principal diagnosis
b. comorbidity
A document that informs a health care provider of a patient’s desire regarding various life-sustaining treatment is a
a. do not resuscitate order
b. health care proxy
c. living will
d. organ donation card
c. living will
Sally Smith is admitted to Sunny Valley Hospital wearing a diamond ring. This should be documented on the
a. face sheet
b. financial record
c. patient property form
d. nursing assessment
c. patient property form
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
a. chief complaint
b. history of the present illness
c. past history
d. patient complaint
a. chief complaint
Progress notes should be written
a. daily
b. weekly
c. on admission and discharge
d. as the patient’s condition warrants
d. as the patient’s condition warrants
An APGAR score is documented in the
a. admission history and physical
b. autopsy report
c. newborn record
d. nursing assessment
c. newborn record
Information concerning the mother’s condition after delivery is documented in the
a. antepartum record
b. delivery record
c. labor record
d. postpartum record
d. postpartum record
The use of electronic health records can accomplish all EXCEPT which of the following:
a. decreased lengths of stay
b. improved health care quality
c. reduced health care costs
d. reduced medical errors
a. decreased lengths of stay
The diagnosis, determined after the evaluation and documented by the attending physician upon discharge from the facility is known as the
a. final diagnosis
b. admitting diagnosis
c. comorbidity
d. complication
a. final diagnosis
Sunny Valley Hospital has adopted the following as part of their patient record documentation guidelines. Determine which guidelines need to be revised because they do not reflect sound documentation practices
- All entries should be documented and signed by the author
- Complete only necessary entries on preprinted forms. Leave others blank
- If other patient(s) are referenced in the record, document their name(s)
- State facts about patient care and treatment; avoid documenting opinions
- Be sure to document specific information and to avoid vague entries
a. 1 and 2
b. 1 and 4
c. 2 and 5
d. 2 and 3
d. 2 and 3
Review the following patient record entry, and determine which report it would be documented in
Skin - no jaundice reveals pale, cool, and moist surface
Chest - respirations normal
Lungs - clear on inspection, percussions, and auscultation
Abdomen - no tenderness, guarding, or rigidity
Extremeties - no significant findings
Genitalia - normal
Rectal - deferred
a. chief complaint
b. history of present illness
c. physical examination
d. review of systems
c. physical examination
A paper or computer based assessment of the patient’s body system is a
a. physical examination
b. history of present illness
c. consultation
d. social history
a. physical examination
A patient’s record contains the following order: “Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks.” This is an example of a
a. discharge order
b. post-anesthesia note
c. postoperative note
d. risk management review
a. discharge order
Dr. Smith documents in a patient’s record that the patient may be released from the recovery room. This would be documented as part of the
a. operative report
b. post-anesthesia note
c. postoperative note
d. case management note
b. post-anesthesia note
Which of the following statements would be found as part of a pre-anesthesia note?
- patient denies any previous reactions to anesthesia
- anesthesia to be used-genera
- patient had no reaction to current surgery
- patient is at risk due to smoking history
a. 1 and 2
b. 2 and 3
c. 1, 2, and 3
d. 1, 2, and 4
d. 1, 2, and 4
Dr. Jones reviews the following information located in the patient record. Determine in which report the information is documented Date Blood Pressure Temperature Weight a. history of present illness b. physical examination c. nursing care plan d. vital signs record
d. vital signs record
The following note is written by Dr. Balby: “Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant.” This information would be documented as part of the
a. ante partum record
b. labor and delivery record
c. prenatal record
d. postpartum record
b. labor and delivery record
Sally Jones assembles a patient record and organizes the following documents into a separate section of the record: advance directives, informed consent, and patient property form. This separate section of the record would be considered
a. administrative data
b. clinical data
c. financial data
d. miscellaneous data
a. administrative data
The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient weights on the day of admission as well as day of discharge. This information can be located on the
a. discharge summary
b. graphic sheet
c. intake/output record
d. nursing progress notes
b. graphic sheet
Dr. Sharp, a surgeon, has designed a new form that he wants to use when he completes cataract surgery. Final approval of the form would be given by the
a. executive board
b. forms committee
c. medical staff
d. surgery committee
b. forms committee
Sally Smith is completing analysis of a patient’s record and finds an original incident report in the record. Which action should she take?
a. file the original incident report in the patient record
b. make a copy of the incident report for the patient’s record and send the original to the risk manager
c. make a copy of the incident report for the risk manager and file the original in the record
d. send the original incident report to the risk manager’s office
d. send the original incident report to the risk manager’s office
Dr. Cook records the following as part of a history and physical examination: “Patient presents with abdominal pain of seven days’ duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out appendicitis vs. obstruction of colon.” The diagnoses recorded are
a. admission diagnoses
b. differential diagnosis
c. primary diagnosis
d. secondary diagnosis
b. differential diagnosis
Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Heart, a cardiologist, to evaluate Mary’s chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the
a. discharge summary
b. interval history and physical
c. report of consultation
d. review of systems
c. report of consultation
A report that describes gross findings, organs examined and techniques for surgery is
a. operative discharge report
b. anesthetic record
c. pathology report
d. operative record
d. operative record
What is not a part of an antepartum record
a. health history of the mother
b. pregnancy risk factors
c. diagnostic reports and other care during the pregnancy
d. fetal strips
d. fetal strips
Which of the following is not documented as part of a consultation
a. consulting physician’s signature
b. diagnosis and findings
c. recommendations and opinions
d. family physician’s name
d. family physician’s name
As Ms. RHIT assembles and analyzes a discharged obstetrical patient's record, she finds the forms listed below. Which should be pulled from the discharged patients record? Face Sheeet Admission history and physical exam Consents Patient's property record Insurance Claim Laboratory reports Antepartum record (copy) Labor and delivery record Incident report Postpartum record a. antepartum record (copy) b. antepartum record (copy), insurance claim, and incident report c. incident report and antepartum record (copy) d. incident report and insurance claim
d. incident report and insurance claim
A patient was admitted with 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)
a. history and physical examination
b. interval history and physical exmaination
c. progress note discussing patient’s condition since April 15
d. short form history and physical examination
a. history and physical examination
Which of the following is documented on the physical exmaination?
a. “I’m feeling very tired lately”
b. patient’s lungs are congested
c. denies loss of hearing
d. Zocar, 40 mg, q.d.
b. patient’s lungs are congested
With alphabetic filing, which name is filed first?
a. B. Polly Kim
b. B. Kim
c. Barbara Polly Kim
d. Brenda Polly Kim
b. B. Kim
