HIM Unit III, Ch 6
What is the primary purpose of patient health information?
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?
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
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
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:
The process of advising a patient about treatment options is known as
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:
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
Progress note should be written:
as the patient’s condition warrants
An Apgar score is documented in the:
Information concerning the mother’s condition after delivery is documented in the:
The provisional autopsy report should be documented within
The major responsibility of a complete and accurate record rests with the
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
Clear on inspection, percussion, and auscultation
No tenderness, guarding, or rigidity
No significant findings
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:
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:
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:
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:
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:
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:
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:
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
Antepartum record copy
Labor and delivery 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?
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:
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: