Ch 4 Health Record Content And Documentation Flashcards
Complete the statement: the pts medical history can be completed within _______ of admission to the hospital
30 days
Justify the need for documentation standards
To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the pt
A new hospital in town wants to accept Medicare pts. To receive Medicare funding, the hospital must meet
The Medicare conditions of participation
The fact that ABC hospital is accredited by an accreditation organization that allows the hospital to also meet the Medicare conditions of participation is known as
Deemed status
Dr S admits pts to ABC hospital. There he is able to perform general surgery, order tests and perform other services. This is known as
Medical staff privileges
True or false: auto-authentication is the preferred method of authentication
False
True or False: only individuals authorized by the healthcare org policy should be allowed to enter documentation in the health record.
True
Each entry in the health record should be
Signed and dated
True or false: when an error is made. The erroneous information can obliterated
False
True or false, health record entries should be documented at the time the services they describe are rendered
True
A pedi growth record may be found in the ______ records
Ambulatory
A medical HX that includes the HX of abuse or neglect & sexual practices is found in the ______ record
Ambulatory
Identify the document that records past & present medical conditions
Problem list
Identify the type of health record that may contain family and caregiver input
Behavioral health records
The RAI is part of the _______ health record
Long term care
True or false Many services such as surgery, infusions and other diagnostics procedures that once required an overnight hospital stay for the patient no longer require that level of care.
True
The patient assessment instrument is completed _____
On admission only
The assessment used by a rehabilitation center is known as:
PAI
The pt assessment instrument is completed ______
On admission and discharge
Ancillary services include which of the following
Dietician services
A pts registration forms, personal property list, RAI, care plan and discharge or transfer documentation would be found most frequently in which type of health record ?
Long term care
The physician spoke to a pt about the risks and benefits of a treatment or procedures. This is known as
Informed consent
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records his or her evaluation documentations known as
Consultation
The originating dept organizes the paper based health record. This is an example of
Source oriented health record
The S in SOAP is
Subjective
As the govt has shifted its focus towards quality, alternative reimbursement & payment models have developed. An example is:
Pay for performance
The healthcare organization needs to incorporate paper based health records into the pt’s EHR. It should use
Document imaging
True or false, pay for performance initiatives focus on treatment quality, efficiency and value rather than the quality
True
Documentation should be authenticated, accurate, legible complete and:
Timely
True or false HIM professionals use the health record for coding
True
True or false HIM professionals are experts in the development of workflows related to the EHR
True
Nursing documentation within the health record is
Objective
True or false, HIM professionals document in the health record
False
Template
A pattern used in EHR’s to capture data in a structured manner. Example birth record template APGAR, weight etc
Medical staff bylaws
Standards that govern the practice of medical staff. Set by staff executive committee and approved by board of directors
A _____ is a summary of the pts problems from the nurse or other professional’s perspective with a detailed plan for intervention.
A care plan
Documentation standards have become more detailed and have become focused on ____
Patient care quality
The Joint commission places an emphasis on _____
Patient care quality
Patient account information includes _____
Insurance
The health record format that is most commonly used by healthcare settings as they transition to electronic records is _____
Hybrid records
An electronic health record tech tool that allows a paper based x-ray report to be accessed is _____
Documents imaging
Which of the following materials is documented in an emergency care record?
Time and means of the patient’s arrival
When defining the legal health record, the healthcare provider must ___
Assess the legal environment
The social an personal history will be found in the _____
Medical history
Which of the following is a long term care setting?
Community mental health center
Complete and accurate health record information _______
Increase quality of treatment
Justify the need for the discharge summary
Providing information to support the activities of the medical staff review committee
An increase of healthcare related identity theft has had influence on a healthcare provider organization’s decision not to collect _____, which is a unique pat identifier.
Social security number
Which of the following types of facilities is generally governed by long term care documentation standards?
Subacute care
which of the following is an example of an acknowledgement
Notice of privacy practices
Which of the following is an electronic record tech capability that allows a paper based x ray report to be accessed?
Documents imaging
Patient history questionnaires are most often used in ______
Ambulatory care
Which of the following statements justifies the need for a consultant report?
It documents opinions about the pt’s condition from the perspective of a physician not previously involved in the pt’s care
When a pt is being transferred from an acute setting to another healthcare organization a ______ may be initiated
Transfer record
Health record entries should be recorded _____
At the time care is provided
Nursing documentation should be _____, not based on the nurses’s opinion.
Objective
Healthcare providers moving from a strictly paper based health record to an electronic format typically transition to _____before establishing a completely electronic based format.
A hybrid reord
Federal and state documentation initiatives as well as the subsequent reimbursement and payment models are now focusing on ______
The efficiency, quality, and value of healthcare services provided
The physicain’s finding based on exam of the pt is located in the _____
physical exam
The H&P should be completed
No more than 30 days prior to admission
The means by which the pt arrived at the healthcare setting and documentation of care provided to stabilize the pt must be documented in the _____health record
Emergency care
Written or spoken permission to proceed with care is classified as _____
Expressed consent
The Subjective, Assessment, Plan came from the _____
Problem oriented health record
Critique each statement to determine the true statement related to correcting errors in the paper based health record entries
The reason for the change should be noted
Home care records typically include ____
An individual treatment plan
The Medicare Access and CHIP reauthorization (MACRA) is a ______
Federal healthcare quality improvement initiative
A healthcare provider org, when defining it’s legal health record must
Assess the legal environment, system limitations and HIE agreements
An RAI/MDS and care plan are found in records of
Long term care
Which of the following is a true statement regarding abbreviations in the health record?
Only abbreviations and symbols approved by the org can be used
Documentation of the pts current and past health status is located in the _____
Medical history
The management of health information is a fundamental component of ____
The overall information governance model
General documentation guidelines apply to ____
All categories of healthcare records
The ambulatory surgery record contains info most similar to _____
Hospital operative records
The overall goal of documentation standards is to _____
Ensure what is documented in the health record is complete and accurately reflects the treatment given to the patient
