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