Chapter 9 Test 3

Question 1

Detract from the chronology of care and increase likelihood of liability
_______ and ______ in time refer to lengths of time when there is no documentation

Answer 1

Gaps and omissions

Question 2

Spaces left between entries in the health record

Answer 2

Gaps

Question 3

Require particular attention to objective documentation

Answer 3

Hostile patients

Question 4

Differing opinions must be documented in the record if pertinent to care
However, documentation should not highlight disagreements
Language must be objective and factual

Answer 4

Staff disagreements

Question 5

Objective and factual documentation

Documentation should include statements made, identification and thorough description of of injuries, and photos

Answer 5

Injuries resulting from criminal activity

Question 6

Heightened if documentation is missing, incomplete, biased, critical, and based on opinions rather than fact

Answer 6

Liability for improper entries

Question 7

Associated with data creation

Emphasis on accuracy and integrity

Answer 7

Data governance

Question 8

Associated with information after it has been created

Emphasis on safeguarding and protection

Answer 8

Information governance

Question 9

Genuineness of a record; that it is what it purports to be

Answer 9

Authenticity

Question 10

Security process that verifies one’s identity and authorizes system access

Answer 10

Authentication

Question 11

Applying a signature to documentation, showing authorship

EX: Paper records and electronic records

Answer 11

Attestation

Question 12

Handwritten signatures; initials; rubber signature stamps (not favored)

Answer 12

Paper records

Question 13

Digitized signature; button, PIN, biometric identifier or token; digital signature (all referred to as electronic signatures)

Answer 13

Electronic records

Question 14

Attestation by a second provider that signifies review and evaluation of the actions and documentation, including attestation, of a first provider.

Answer 14

Countersignatures

Question 15

Several staff members complete documents such as assessments at different times, requiring ________. They should sign a date and indicate the sections they completed.

Answer 15

Multiple attestations

Question 16

When an author can no longer attest to documentation to validate accuracy, like a resign or death, there are alternate signers who are familiar with the case.

Answer 16

Attestation on behalf of another

Question 17

Occurs when failure of an author to review and actively approve or disapprove an entry in an EHR within a specified time period results in ____

Answer 17

Auto-attestation

Question 18

Attesting to multiple entries or orders at one time. Acceptable when reviewed and not acceptable when the provider signs the entries or orders without reviewing first.

Answer 18

Batch signing

Question 19

Person who documents in the health record for the provider. Must be uniquely identified and Provider must attest to the entries upon review.

Answer 19

Scribes

Question 20

Provides background information about actions that affect creation, revision, and access to data

Answer 20

Metadata

Question 21

Increase efficiency and structure, but create integrity issues

Answer 21

Documentation templates

Question 22

Degree to which information in the record reflects what actually happened

Answer 22

Accuracy

Question 23

Information may be placed on wrong encounter or wrong patient
- Medical Plagiarism
Risks of healthcare fraud when documentation from another provider or another patient’s record is used

Answer 23

Authorship and Cut, Copy, Paste (Cloning)

Question 24

Using another’s documentation without permission

Answer 24

Medical Plagiarism

Question 25

Must use only organization-approved ________.

Must not use Joint Commission prohibited ________.

Answer 25

Abbreviations

Question 26

Physician handwriting

Answer 26

Legibility

Question 27

Changes should be made ONLY per organizational policy
Revisions
Late entry
Amendment
Addendum
Removal 
Version Management

Answer 27

Health Record

Question 28

Replacing inaccurate information with accurate information after attestation

Answer 28

Revisions

Question 29

Entry missed or not written in timely manner

Answer 29

Late entry

Question 30

Information added to support or clarify (HIPAA individual right)

Answer 30

Amendment

Question 31

New documentation added to original entry after attestation

Answer 31

Addendum

Question 32

Permanent elimination of information (limited, if permitted at all)

Answer 32

Deletion

Question 33

Information no longer available for viewing but is available in the background

Answer 33

Retraction

Question 34

What are two types of removal?

Answer 34

Deletion and Retraction

Question 35

How an organization handles numerous iterations of a document
If used for patient care, must be retained

Answer 35

Version management

Question 36

Promptness of documentation

Answer 36

Timeliness

Question 37

Comprehensiveness of documentation
Mandated by accrediting and licensure bodies
Important from evidentiary standpoint

Answer 37

Completeness

Question 38

Types of PHRs?

Answer 38

Standalone PHRs

Tethered PHRs

Question 39

Information provided by the patient, either by paper, computer or thumb drive, or internet repository of their choosing

Answer 39

Standalone PHRs

Question 40

Connected to a secure electronic portal to an organization’s information system, like an EHR.

Answer 40

Tethered PHRs