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HITT 1301 > Ch 4 Health Record Content And Documentation > Flashcards

Ch 4 Health Record Content And Documentation Flashcards

1
Q

Complete the statement: the pts medical history can be completed within _______ of admission to the hospital

A

30 days

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2
Q

Justify the need for documentation standards

A

To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the pt

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3
Q

A new hospital in town wants to accept Medicare pts. To receive Medicare funding, the hospital must meet

A

The Medicare conditions of participation

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4
Q

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

A

Deemed status

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5
Q

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

A

Medical staff privileges

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6
Q

True or false: auto-authentication is the preferred method of authentication

A

False

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7
Q

True or False: only individuals authorized by the healthcare org policy should be allowed to enter documentation in the health record.

A

True

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8
Q

Each entry in the health record should be

A

Signed and dated

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9
Q

True or false: when an error is made. The erroneous information can obliterated

A

False

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10
Q

True or false, health record entries should be documented at the time the services they describe are rendered

A

True

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11
Q

A pedi growth record may be found in the ______ records

A

Ambulatory

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12
Q

A medical HX that includes the HX of abuse or neglect & sexual practices is found in the ______ record

A

Ambulatory

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13
Q

Identify the document that records past & present medical conditions

A

Problem list

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14
Q

Identify the type of health record that may contain family and caregiver input

A

Behavioral health records

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15
Q

The RAI is part of the _______ health record

A

Long term care

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16
Q

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.

A

True

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17
Q

The patient assessment instrument is completed _____

A

On admission only

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18
Q

The assessment used by a rehabilitation center is known as:

A

PAI

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19
Q

The pt assessment instrument is completed ______

A

On admission and discharge

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20
Q

Ancillary services include which of the following

A

Dietician services

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21
Q

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 ?

A

Long term care

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22
Q

The physician spoke to a pt about the risks and benefits of a treatment or procedures. This is known as

A

Informed consent

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23
Q

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

A

Consultation

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24
Q

The originating dept organizes the paper based health record. This is an example of

A

Source oriented health record

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25
Q

The S in SOAP is

A

Subjective

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26
Q

As the govt has shifted its focus towards quality, alternative reimbursement & payment models have developed. An example is:

A

Pay for performance

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27
Q

The healthcare organization needs to incorporate paper based health records into the pt’s EHR. It should use

A

Document imaging

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28
Q

True or false, pay for performance initiatives focus on treatment quality, efficiency and value rather than the quality

A

True

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29
Q

Documentation should be authenticated, accurate, legible complete and:

A

Timely

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30
Q

True or false HIM professionals use the health record for coding

A

True

31
Q

True or false HIM professionals are experts in the development of workflows related to the EHR

A

True

32
Q

Nursing documentation within the health record is

A

Objective

33
Q

True or false, HIM professionals document in the health record

A

False

34
Q

Template

A

A pattern used in EHR’s to capture data in a structured manner. Example birth record template APGAR, weight etc

35
Q

Medical staff bylaws

A

Standards that govern the practice of medical staff. Set by staff executive committee and approved by board of directors

36
Q

A _____ is a summary of the pts problems from the nurse or other professional’s perspective with a detailed plan for intervention.

A

A care plan

37
Q

Documentation standards have become more detailed and have become focused on ____

A

Patient care quality

38
Q

The Joint commission places an emphasis on _____

A

Patient care quality

39
Q

Patient account information includes _____

A

Insurance

40
Q

The health record format that is most commonly used by healthcare settings as they transition to electronic records is _____

A

Hybrid records

41
Q

An electronic health record tech tool that allows a paper based x-ray report to be accessed is _____

A

Documents imaging

42
Q

Which of the following materials is documented in an emergency care record?

A

Time and means of the patient’s arrival

43
Q

When defining the legal health record, the healthcare provider must ___

A

Assess the legal environment

44
Q

The social an personal history will be found in the _____

A

Medical history

45
Q

Which of the following is a long term care setting?

A

Community mental health center

46
Q

Complete and accurate health record information _______

A

Increase quality of treatment

47
Q

Justify the need for the discharge summary

A

Providing information to support the activities of the medical staff review committee

48
Q

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.

A

Social security number

49
Q

Which of the following types of facilities is generally governed by long term care documentation standards?

A

Subacute care

50
Q

which of the following is an example of an acknowledgement

A

Notice of privacy practices

51
Q

Which of the following is an electronic record tech capability that allows a paper based x ray report to be accessed?

A

Documents imaging

52
Q

Patient history questionnaires are most often used in ______

A

Ambulatory care

53
Q

Which of the following statements justifies the need for a consultant report?

A

It documents opinions about the pt’s condition from the perspective of a physician not previously involved in the pt’s care

54
Q

When a pt is being transferred from an acute setting to another healthcare organization a ______ may be initiated

A

Transfer record

55
Q

Health record entries should be recorded _____

A

At the time care is provided

56
Q

Nursing documentation should be _____, not based on the nurses’s opinion.

A

Objective

57
Q

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

A hybrid reord

58
Q

Federal and state documentation initiatives as well as the subsequent reimbursement and payment models are now focusing on ______

A

The efficiency, quality, and value of healthcare services provided

59
Q

The physicain’s finding based on exam of the pt is located in the _____

A

physical exam

60
Q

The H&P should be completed

A

No more than 30 days prior to admission

61
Q

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

A

Emergency care

62
Q

Written or spoken permission to proceed with care is classified as _____

A

Expressed consent

63
Q

The Subjective, Assessment, Plan came from the _____

A

Problem oriented health record

64
Q

Critique each statement to determine the true statement related to correcting errors in the paper based health record entries

A

The reason for the change should be noted

65
Q

Home care records typically include ____

A

An individual treatment plan

66
Q

The Medicare Access and CHIP reauthorization (MACRA) is a ______

A

Federal healthcare quality improvement initiative

67
Q

A healthcare provider org, when defining it’s legal health record must

A

Assess the legal environment, system limitations and HIE agreements

68
Q

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

A

Long term care

69
Q

Which of the following is a true statement regarding abbreviations in the health record?

A

Only abbreviations and symbols approved by the org can be used

70
Q

Documentation of the pts current and past health status is located in the _____

A

Medical history

71
Q

The management of health information is a fundamental component of ____

A

The overall information governance model

72
Q

General documentation guidelines apply to ____

A

All categories of healthcare records

73
Q

The ambulatory surgery record contains info most similar to _____

A

Hospital operative records

74
Q

The overall goal of documentation standards is to _____

A

Ensure what is documented in the health record is complete and accurately reflects the treatment given to the patient

HITT 1301 (9 decks)

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