III- Health data content and standards

Question 1

In preparation for an EHR, you are working with a team conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is…

• operative report.
• recovery room record.
• pathology report.
• discharge summary.

Answer 1

Pathology report

Question 2

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Answer 2

Cognitive Patterns

Question 3

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Answer 3

use of prohibited or “dangerous” abbreviations

Question 4

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Answer 4

incident report

Question 5

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Answer 5

Problem list

Question 6

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Answer 6

evidence cannot be provided that the physician actually reviewed and approved each report.

Question 7

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Answer 7

prenatal record

Question 8

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Answer 8

the H&P copy is acceptable as long as she documents any interval changes.

Question 9

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Answer 9

disease index

Question 10

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Answer 10

significant findings durring hospitalization

Question 11

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Answer 11

the overall quality of the documentation

Question 12

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Answer 12

attending physician

Question 13

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Answer 13

interdisaplinary plan of care

Question 14

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Answer 14

marking the surgical site

Question 15

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Answer 15

0.4 mg lasix

Question 16

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Answer 16

assessment

Question 17

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Answer 17

opperation index

Question 18

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Answer 18

nurses using bedside terminals to record vital signs

Question 19

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Answer 19

pharmacy consultaion

Question 20

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Answer 20

federal register

Question 21

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Answer 21

time and means of arrival

Question 22

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Answer 22

patient states low back pain is as severe as it was on addmission

Question 23

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Answer 23

physical assessment

Question 24

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Answer 24

24 hours after admission or prior to surgery

Question 25

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Answer 25

operative record

Question 26

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Answer 26

general appearance as assessed by the physician

Question 27

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Answer 27

disease index

Question 28

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Answer 28

Impressions of a cardiologist asked to determine whether patient is at good surgical risk

Question 29

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Answer 29

the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed

Question 30

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Answer 30

integrated progress notes

Question 31

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Answer 31

required for reimbursment of certain patient groups

Question 32

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Answer 32

problem list

Question 33

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Answer 33

discharge summary

Question 34

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Answer 34

Recovery audit contractors

Question 35

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Answer 35

documented in both the progress notes and the discharge summary

Question 36

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Answer 36

medical staff rules and regulations

Question 37

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Answer 37

admitting diagnosis

Question 38

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Answer 38

physical exam

Question 39

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Answer 39

uniquely identify the patient

Question 40

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Answer 40

health record

Question 41

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Answer 41

all of these choices

Question 42

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Answer 42

U.S. patriot act

Question 43

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Answer 43

Patient care outcomes

Question 44

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Answer 44

QIO scope of work

Question 45

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Answer 45

incident report

Question 46

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Answer 46

continued stay review

Question 47

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Answer 47

outcome measures

Question 48

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Answer 48

pathology reports

Question 49

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Answer 49

all of these

Question 50

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Answer 50

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Question 51

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Answer 51

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