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
