HIM Unit III, Ch 6

What is the primary purpose of patient health information?
Patient care

Who is responsible for ensuring the quality of health record documentation?

Which of the following statements about the legal health record or the designated records sent is incorrect?
Designated records that is determined by the medical staff.

Of the following which is the most likely to happen to the health records of the physician’s patient when a physician leaves and office practice?
Retained by the practice

Once a paper health record has been converted onto microfilm, the information cannot be used as evidence

The legal health record:
Will be disclosed upon request

The legal health record must meet requirements as defined by the following:
All of the above

Verbal orders by telephone or in person or discouraged. In cases were verbal orders are necessary, which of the following is the most effective method by which the risk of miscommunication can be lessened?
Person receiving the order should read it back to ensure that the order is correct

Which of the following exemplifies an acceptable patient record entry?
Patient articulated pain level as of six

Every report in the patient record must contain patient identification data.

The Uniform Rules of Evidence states that for a record to be admissible in court of law, all patient record entries must be dated and timed.

And advanced directive and an informed consent are considered clinical data

The admitting diagnosis is the condition or disease for which the patient is seeking treatment.

Third-party payer information is classified as financial data, and it is obtained from the patient at admission

A complication is a pre-existing condition that will cause an increase in the patient’s length of stay by at least one day

The principal procedure is performed for definitive or therapeutic reasons

Health information personnel who extract records assign ICD -9 – CM codes to diagnoses and procedures

The Healthcare Financing Administration is now called the centers for Medicare and Medicaid Services

Up coding or maximizing codes is considered DRG Creep

The Patient Self – Determination Act of 1990 requires all healthcare facilities to notify patients age 21 and over that they have the right to have an advance directive

A living will is a written document informs a healthcare provider of the patient’s desires regarding life – sustaining treatment

Persons under 18 years of age must have their parents or guardian consent to donate organs

The Joint Commission Standards requires a patient’s consent to treatment and that the record contain evidence of consent

A consent to admission documents the patient’s consent for all medical treatment including procedures and surgeries to be completed during the current admission

The National Center for Health Statistics developed a standard certificate of birth that states adopt for their use

AOA requirements state for the patient record must be maintained for each patient treated in emergency department

A discharge progress note can be documented in the patient record instead of the discharge summary if the patient had an uncomplicated hospital stay of less than 48 hours

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

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

A consultation includes the examination of the patient by specialist who also provides an opinion or advice

All orders must be authenticated by the responsible provider

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

An admission note documented by the attending physician can replace a dictated history and physical examination

Pre-anesthesia and post anesthesia progress notes are often documented on a separate form to facilitate documentation by the anesthesiologist

The pathology report assists in the diagnosis and treatment of patients by documenting analysis of tissue removed surgically

The name of the attending physician is considered patient identification information

Electro cardiogram (EKG) reports include a graphic print out of measurements of electrical activity of the brain

All ancillary reports should be filed in the patient’s record within 24 hours after interpretation of test results

The postpartum record is started in the physicians office and includes all tests performed, pregnancy risks, and care given

The documentation of emergency services provided prior to admission is considered clinical/case information

Medicare Conditions of Participation (CoP) categorize outpatient care as optional hospital services and require the hospital to maintain a medical record for each outpatient

The appearance of an outpatient to a hospital department is called an encounter

A licensed nurse is required to have a public license to deliver care to patients

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

Ready – to – use forms are often more expensive to purchase and therefore are not used by many facilities

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

Progress notes facilitate healthcare team communication, which is crucial to quality care

The forms committee oversees the process of new forms control and design

The death certificate is usually filed with state Department of Health office of vital statistics within five days

Which is an example of clinical data?
Anesthesiology report

Which statement regarding the patient record is true
All entries must be legible and complete

The diagnosis that documents the condition or disease for which the patient is seeking treatment is the
Provisional diagnosis

A pre-existing condition that causes an increase in the patient’s length of stay by at least one day in 75% of the cases is known as

The name, address, phone number of the third – party payer is considered
Financial data

Every report and every page/screen in the manual or computerized patient record must include
Patient name and identification number

The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the
Uniform Hospital Discharge Data Set

A patient is admitted for congestive heart failure and hypertension. During the admission the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a:

The document that informs a healthcare provider of the patient’s desire regarding various life – sustaining treatment is a:
Living Will

The process of advising a patient about treatment options is known as
Informed consent

Sally Smith is admitted to Sunny Valley Hospital wearing a diamond ring. This should be documented on the
Patient property form

Birth certificate information is usually submitted to the ______ within 10 days of birth
State Department of health or offices of vital statistics

The joint commission requires the discharge summary be completed within _______ days of discharge

Dr. Smith has 10 patient records that are delinquent. The action that could be taken by the hospital includes
Suspension of physician privileges

When a patient is transferred to a different level of care within the same hospital, the summary report is called a:
Transfer summary

Dr. Jones completes an admission history and physical on Bob Lot, who states, “when I walk upstairs, I have difficulty breathing.” This statement is known as the patient’s
Chief complaint

Progress note should be written:
as the patient’s condition warrants

An Apgar score is documented in the:
Newborn record

Information concerning the mother’s condition after delivery is documented in the:
Postpartum record

The provisional autopsy report should be documented within
Three days

The major responsibility of a complete and accurate record rests with the
Attending physician

Sunny Valley hospital has adopted the following as part of its patient record documentation guidelines. Determine which guidelines need to be revised because they do not reflect sound documentation practices
Complete only necessary entries on preprinted forms. And if other patients are referenced in the record, document their names

Review the following patient record entry, and determine which report it would be documented:

No jaundice reveals pale, cool, and moist surface
Respirations normal
Clear on inspection, percussion, and auscultation
No tenderness, guarding, or rigidity
No significant findings

Physical examination

Dr. Smith enters the following information as part of a progress note: 2/3/why why why. Patient complains of right upper abdominal pain of four days duration. This information represents the:
Chief complaint

A patient’s record contains the following order: “Mary Black is stable and has no complaints of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks. This is an example of the a:
Discharge order

Dr. Smith documents the patient’s record that the patient may be released from the recovery room. This would be documented as part of the
Post anesthesia note

Which of the following statements would be found as part of the preanesthesia note?
Patient denies any previous reactions to anesthesia, anesthesia is to be used – Gen., patient is at risk due to smoking history

Dr. Jones reviews the following information located in the patient record. Determine which report the information is documented. Insert photograph
Vital signs record

The following note is written by Dr. Balby: onset of contractions started at 4 AM. Patient refused medications. Normal presentation. Outcome of delivery: single male infant. This information would be documented as part of the
Labor and delivery record

Dr. Health sees Jack in her office to monitor his blood chemistry. She completes an examination and orders blood tests. Her medical assistant completes the venipuncture. Charges for the services would be recorded on an:
Encounter form

Sally Jones assembles the patient record and organizes the following documents into a separate section of the record: facesheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered:
Administrative data

Ms. RHIT is developing an audit tool to be used to review records in preparation for the joint commission survey. Which of the following is standard that should be included on the audit tool?
The record needs to document evidence of appropriate informed consent

The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient waits on the day of admission as well as date of discharge. This information can be located on the:
Graphic record

Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the:
Forms committee

Sally Smith is completing analysis of the patient’s record and finds an original incident report in the record. Which action should you take?
Send the original incident report to risk managers office

Dr. Cook records the following as part of the history and physical examination: patient presents with abdominal pain of seven days duration. Fever and chills for the last three days. Diagnoses at the time of admission: rule out appendicitis versus obstruction of colon. The diagnoses recorded are:
differential diagnoses

Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Hart, a cardiologist, to evaluate Mary’s chest pain. Dr. Hart would document his examination of the patient, pertinent findings, recommendations, and opinions on the:
Report of consultation

Nurse Smith believes that inpatient Tom Jones needs to have physical therapy because his gait is unsteady when she works him. Which of the following would occur?
Nurse Smith should discuss your observations with Tom’s attending physician

In which of the following cases with documentation of an interval history be acceptable?
74 – year – old readmitted for pneumonia seven days following discharge for this condition

Which of the following observations would be found in the physical examination report?
Abdomen soft and tender with no rebound tenderness

Which of the following is not documented as part of a consultation report?
Signature of requesting physician

“As Ms. RHIT assembles and analyzes a discharge obstetrical patient’s record, she finds the forms listed below. Which should be pulled from the discharge patients record?
Admission history and physical exam
Patients property record
Insurance claim
Laboratory reports
Antepartum record copy
Labor and delivery record
Incident report
Postpartum record
Incident report and insurance claim

A patient was admitted with chronic obstructive pulmonary disease COPD on April 15 this year. The patient has an exacerbation of COPD and was readmitted on June 1 this year. The physician needs to document an:
History and physical examination

Molly makes was admitted to Sun Valley Hospital on January 22 this year for pneumonia. The history and physical examination of HNP was placed on the record January 24 this year. Determine which of the following statements is true based on joint commission standards
The record is not in compliance, as the H&P needs to be completed within 24 hours

Ms. RHIT is analyzing and assembling to patients record and notices the copy of the history and physical from the attending physician’s office was used in the record instead of an inpatient history and physical. The office H&P was completed on January 2 this year and the patient was admitted to the hospital on January 5 this year; the office H&P was placed on the record at the time of admission. According to Medicare CoP regulations, the office H&P is:
Acceptable as the H&P for this admission because it was completed no more than seven days prior to admission

Which of the following is documented on the physical examination?
Patient’s lungs are congested

Which of the following would not be documented on the medication administration record?
Provisional diagnosis

Which of the following documents that the patient acknowledges the nature of treatment, risk, and complications of care?

The hospital record that documents diagnostic, therapeutic, and rehabilitation services of outpatients is the:
Ambulatory record

Dr. Smith wants to implement a new form to record post operative complications. This should be reviewed to be approved for use in medical record by the:
forms committee

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