Question 1

A patient record serves as a business record for the patient encounter and contains administrative data.

Accepted Answer

T

Question 2

The medical record is the property of the provider.

Accepted Answer

T

Question 3

Administrative data includes demographic, socioeconomic, and financial information

Accepted Answer

T

Question 4

A consultation report, history and physical exam, and operative reports are all types of administrative dat

Accepted Answer

F

Question 5

The legibility of patient care record entries impacts patient care

Accepted Answer

T

Question 6

Inpatient record creation may begin prior to admission when preadmission testing is performed

Accepted Answer

T

Question 7

Most facilities organize the patient record according to reverse chronological order during inpatient hospitalization.

Accepted Answer

T

Question 8

Clinical data includes all patient medical information

Accepted Answer

T

Question 9

Source oriented records consist of a database, problem list and initial plan and progress notes.

Accepted Answer

F

Question 10

A potentially compensable event is an accident or medical error that results in personal injury or loss of property.

Accepted Answer

T

Question 11

The electronic health record facilitates the creation of a longitudinal patient record.

Accepted Answer

T

Question 12

Patients do not have the right to access or review contents of their records

Accepted Answer

F

Question 13

Continuity of care includes documentation of patient care services so that others that treat the patient have a source of information on which to provide additional care and treatment.

Accepted Answer

T

Question 14

A living will is a written document that informs a health care provider of a patient’s desires regarding life sustaining treatment.

Accepted Answer

T

Question 15

A delinquent record can result in suspension of a physician’s medical staff privileges

Accepted Answer

T

Question 16

The history of the present illness is the patient’s description of his current medical condition in his own words

Accepted Answer

F

Question 17

Integrated progress notes are documented by physicians, nurses, therapists, and other professionals in the same section of the patient record

Accepted Answer

T

Question 18

A physician's order can be considered a "prescription" for care.

Accepted Answer

T

Question 19

A Preoperative note is a progress note documented by the surgeon prior to surgery

Accepted Answer

T

Question 20

EKG reports include a graphic printout of measurements of the activity of the brain

Accepted Answer

F

Question 21

The appearance of an outpatient to a hospital department to receive an ordered service, test or procedure is called an encounter.

Accepted Answer

F

Question 22

The role of a forms committee is to review all proposed forms to be used in the patient record

Accepted Answer

T

Question 23

An autopsy must be authorized by the deceased’s next of kin, except when it is a coroner’s case.

Accepted Answer

T

Question 24

The patient history documents the patient’s chief complaint, history of the present illness, past/family/social history and review of systems.

Accepted Answer

T

Question 25

Electronic Health records will improve care and reduce medical mistakes and costs

Accepted Answer

T

Question 26

The use of a serial numbering system does not need computer software to track the assignment of patient numbers.

Accepted Answer

T

Question 27

Patient records are filed in one location in the filing system when a unit or serial unit numbering system is used.

Accepted Answer

T

Question 28

In a unit numbering system, each time a patient is registered, a new patient number is assigned.

Accepted Answer

F

Question 29

A unit numbering system requires the retrieval of a patient’s record from multiple locations in the filing system when previous records are requested by a physician.

Accepted Answer

F

Question 30

Terminal digit numbers are usually written with a hyphen separating each part of the number.

Accepted Answer

T

Question 31

Patients have the right to have their record amended if they disagree with its content, or have a letter which clarifies their view attached to the record.

Accepted Answer

T

Question 32

An assisted living facility is a combination of housing and support services

Accepted Answer

T

Question 33

Color-coding allows misfiles to be easily identified

Accepted Answer

T

Question 34

Chart tracking systems help to control the file area and facilitate accurate tracking.

Accepted Answer

T

Question 35

A patient monitoring system includes systems that collect demographic information

Accepted Answer

F

Question 36

Births, deaths, fetal deaths, marriages and divorces are examples of vital statistics

Accepted Answer

F?

Question 37

In consecutive numeric filing, records are filed in chronological order according to the patient’s birth date.

Accepted Answer

F

Question 38

A summary of a set a data using charts graphs and tables is referred to as descriptive statistics

Accepted Answer

T

Question 39

39. Which is an example of clinical data? a. date of birth c. patient name b. diagnosis d. social security number

Accepted Answer

B

Question 40

40. An admission clerk enters “right lower abdominal pain” as the admission diagnosis on the face sheet. This information is known as a. administrative data. c. demographic data. b. clinical data . d. financial data.

Accepted Answer

B

Brainscape's Knowledge GenomeTM

Module 2 Flashcards

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