Chapter 4 Quiz Flashcards
Which is the goal of both manual and electronic patient records?
a. documentation of patient care
b. medico legal protection of providers
c. reimbursement of health care services provided.
d. research and education
A
Which is most important for medico legal purposes?
a. discharge summary
b. entire record
c. nurses notes
d. progress notes
B
Although hospital inpatient records have traditionally served as the documentation source and business record for patient care information,
a. all patient records contain similar content and format features.
b. alternate care facilities records serve as the best documentation source for patient care information.
c. patient identification information must be captured by the physician’s office that treats the patient.
d. The definition and purpose of the patient record is supported only by the financial record.
A
Information capture is the process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care. Which is an example of information capture?
a. Analyzing patient information.
b. constructing a health care document (paper or digits).
c. formatting and /or structuring captured information.
d. generating images through X-rays
D
The primary purpose of the patient record is to provide continuity of care, which means
a. documenting services so others have a source from which to base care.
b. evaluating the quality of patient care.
c. providing information to third-party payers for reimbursement.
d. serving the medico legal interests of the patient, facility, and providers of care.
A
Which of the following statements are accurate?
a. The medical record is the property of both the provider and patient.
b. The medical record is the property of the provider.
c. The patient owns the documents in the medical record.
d. The provider owns the information in the medical record.
B
Ms. Wright is a long standing patient of Dr. Bartron’s medical practice. Mrs. Wright also happens to be credentialed health information professional, and she comes to the physicians’ office to request access to her medical record. She wants to make sure that the recent history that was documented by Dr. Bartron accurately reflects statements about her recent car accident. The receptionist has Mrs. Wright sign an authorization to release information and arranges to supervise Mrs. Wright’s review of the record. Upon review, Mrs. Wright determines that there is an error in the documentation of the record and she approaches the medical assistant to request that it be corrected. How should the medical assistant respond? The medical assistant informs Mrs. Wright that
a. Because the receptionist shouldn’t have let Mrs. Wright review the record in the first place, her request for correction is denied.
b. Dr. Bartron does not correct entries in the medical record, but Mrs. Wright can write a letter clarifying the information, which will be filed in the record
c. medical record entries can be corrected only after Mrs. Wright submits a letter that clarifies the information that she wants changed.
d. she has the right to access the contents for review and to request the physician to amend the record to correct inaccurate information.
D
The hospital inpatient record documents the care and treatment received by a patient admitted to the hospital. Where is the paper-based record stored while the patient is in the hospital?
a. All patient records are stored in the health information department.
b. Each record is housed in the location specified in the physician’s order.
c. The inpatient record is typically located at the nursing station.
d. The record is placed in a locking wall desk at the nursing station.
C
Since the early 1980’s, provision of outpatient services has steadily increased due to cost savings associated with providing health care on an ambulatory instead of an inpatient basis. This shift from inpatient to outpatient care has also resulted in hospital health information departments managing a (n)
a. decreasing volume of outpatient information.
b. equal volume of inpatient and outpatient information.
c. fluctuating volume of outpatient information.
d. increasing volume of outpatient information.
D
Patient health care services received in a physician’s office are documented in the physician office record, which includes both administrative and clinical data. Generally, physicians who practice independently use a (n) used by physicians in a group practice.
a. less structured office record versus a more structured office record.
b. more structured office record versus a less structured office record.
c. office record that is very similar in comparison to the hospital inpatient’s record.
d. structured office record similar to that.
A
One of the statements below is an interpretation of the familiar phrase, “if it wasn’t documented, it wasn’t done” in the following care: Dr. White performed a thyroid biopsy procedure at the patient’s bedside. He didn’t document it in the patient’s record. Which statement is correct?
a. The heath care facility should reprimand Dr. White and possibly suspend his privileges
b. The patient has no legal recourse to bring a malpractice suit against the physician.
c. The physician is not allowed to add documentation of the procedure after the fact.
d. Upon review of the record, the third-party payer can refuse to pay for the procedure.
D
Health care services rendered must be documented to prove that care was provided and that good medical care is supported by patient record documentation. Therefore, inadequate patient record documentation may indicate
a. an illegible entry should be rewritten by it’s author.
b. enhanced continuity of care.
c. poor health care delivery.
d. the need to adopt an auto authentication policy.
C
Dr Broad dictated a discharge summary on July 15, which was transcribed and placed in the patient record later the next day. Upon review of the report, Dr Broad decided not to authenticate it and re-dictate it. He told the medical transcriptionist the reason was that, when he originally dictated the report, he has been ill with the flu: the report is incomplete and doesn’t flow properly. Dr Broad drew one line across each page of the report, wrote “re-dictated” on it, and dated and signed the notation. After the transcriptionist transcribes the new dictation, what action should the file clerk take? The file clerk should:
a. insert the newly transcribed report after the old report.
b. place the newly transcribed repot on top of the other report.
c. remove the original report from the record and insert the newly transcribed report.
d. use a permanent marker to redact the old report, and file the new report
B
A technical control mechanism created by an electronic health record system that consists of a listing of all transactions and activities that occurred, along with date, time, and user who performed the transaction is called a (n)
a. addendum
b. amended record
c. audit trail
d. indexed record
C
Preadmission testing (PAT) incorporates patient registration, testing, and other services into one visit prior to
a. ancillary services.
b. emergency care.
c. inpatient care.
d. urgent care.
C
