Chapter 4 - Health Record Content & Documentation

A care plan

A _____ is a summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for intervention A) Clinical observation B) Progress note C) Therapeutic procedure note D) A care plan

Outpatient treatment centers

Ambulatory facilities that perform surgery are called_______. A) Emergency departments B) Outpatient treatment centers C) Ancillary department D) Ambulatory surgery centers

Long-term care

An RAI/MDS & care plan are found in records of ______ patients. A) Behavioral healthcare B) Long-term care C) Home healthcare D) Rehabilitative care

Deemed status

An accreditation organization must participate in its own CMS review in order to receive __________, allowing the accreditation organization to survey other healthcare providers for compliance. A) Accreditation B) Deemed status C) Authorization D) Acknowledgment

Social security number

An increase of healthcare-related identity theft has had influence on a healthcare provider organization's decision not to collect ________, which is a unique patient identifier. A) Social security number B) Account number C) Insurance number D) Health record number

Orders for x-rays, CT, MRI

Diagnostic orders include _______. A) Orders for medication B) Orders for x-rays, CT, MRI C)Orders for therapies D) Orders for admission

Medical history

Documentation of the patient's current and past health status is located in the ________. A) Patient consent B) Physical exam C) Physical orders D) Medical history

Patient care quality

Documentation standards have become more detailed & have become focused on ___________. A) Accreditation standards B) EHR technology C) Patient care quality D) Licensure requirements

The efficiency, quality, and value of healthcare services provided

Federal and state documentation initiatives as well as the subsequent reimbursement and payment models are now focusing on ________. A) The efficiency, quality, and value of healthcare services provided B) The quality of the healthcare services provided C) The efficiency and value of the healthcare services provided D) the quantity of the healthcare services provided.

All categories of healthcare records

General documentation guidelines apply to ________. A) Clinical observations B) Only electronic health records C) All categories of healthcare records D) Only emergency health records

At the time care is provided

Health record entries should be recorded _________. A) Within 24 hours of care B) Prior to the patient leaving the healthcare organization C) On the same day that the care is provided D) At the time care is provided

A hybrid record

Healthcare providers moving from a strictly paper-based health record to an electronic format typically transition to _________ before establishing a completely electronic based format. A) A Care area assessment B) An acknowledgement C) Document imaging D) A hybrid record

Individualized treatment plan

Home care records typically include a(n) _______. A) Operative report B) Pathology report C) APGAR scores D) Individualized treatment plan

Physical examination

Identify the documentation that records the attending physician's assessment of the patient's current health status: A) Progress notes B) Discharge summary C) Physical examination D) Medical history

Commission on Accreditation of Rehabilitation Facilities

Identify the group that is the primary accreditation organization for facilities that treat individuals who have functional disabilities: A) Commission on Accreditation of Rehabilitation Facilities B)Joint Commission C) Accreditation Association for Ambulatory Healthcare D) American Osteopathic Organization

Objective

Nursing documentation should be ______, not based on the nurses opinion. A) Based on SOAP documentation B) Subjective C) Subjective and objective D) Objective

Ambulatory care

Patient history questionnaires are most often used in _____. A) Home healthcare B) Long-term care C) Ambulatory care D) Rehabilitative care

No more than 30 days prior to admission

The H&P should be completed A) At least 30 days prior to admission B) No more than 15 days prior to admission C) At least 15 days prior to admission D) No more than 30 days prior to admission

Federal healthcare quality improvement initiative

The Medicare Access and CHIP Reauthorization Act (MACRA) is an ___________ A) Accrediting organization B) New privacy law C) Federal healthcare quality improvement initiative D) New federal insurance program

Problem-oriented health record

The Subjective, Objective, Assessment Plan (SOAP) came from the _________. A) Problem-oriented health record B) Depends on healthcare organization policy C) Source-oriented health record D) Hybrid health record

Prenatal

The health record that captures the documentation related to the treatment a pregnant patient received before giving birth is called _______. A) Therapeutic B) Inpatient C) Obstetric D) Prenatal

Conditions of Participation

The healthcare organization has decided to treat Medicare patients therefore, they must meet the_______ A) Terms of Accreditation B) Conditions of Participation C) Regulation for Licensure D) Requirements for Service

The overall information governance model

The management of health information is a fundamental component of ___________. A) The overall information governance model B) Cloud computing C) The EHR workflows D) The documentation standards used in the EHR

Emergency care

The means by which the patient arrived at the healthcare setting & documentation of care provided to stabilize the patient must be documented in the _______ health record. A) Ambulatory care B) Emergency care C) Long-term care D) Rehabilitative care

Ensure what is documented in the health record is complete & accurately reflects the treatment provided to the patient

The overall goal of documentation standards is to ______. A) Ensure that the healthcare provider organization is reimbursed appropriately by payers B) Ensure physicians have access to the health record information they need to care for the patient C) Ensure that the Centers for Medicare & Medicaid Services (CMS) don not find reasons to fine the healthcare provider organization D) Ensure what is documented in the health record is complete & accurately reflects the treatment provided to the patient

Physical exam

The physician's findings based on an examination of the patient is located in the _____. A) Discharge summary B) Medical history C) Patient instructions D) Physical exam

Acknowledgement

The property & valuables document that address the fact that the healthcare provider organization is not responsible for the loss or damage of patient valuables & the patient signs is considered a (n) ________. A) Acknowledgement B) Authorization C) Consent D) Note

Medical history

The social and personal history will be found in the ____. A) Care plan B) Medical history C) Physical exam D) Clinical observation

Template

To capture data in a specific manner, the EHR should use ________. A) Database B) Document imaging C) Template D) Core measures

Transfer record

When a patient is being transferred from an acute setting to another healthcare organization, a _________ may be initiated. A) Discharge summary B) Clinical diagnosis C) Transfer record D) Consultation report

Assess the legal environment

When defining the legal health record, the healthcare provider must _______. A) Assess the legal environment B) Determine what the other healthcare providers are doing C) Decide if the legal health record is needed D) Include only the paper components of the health record

Print "addendum" above the entry

Which is the appropriate method for correcting information in a paper health record? A) Backdate to the date that the addendum covers B) Print "addendum" above the entry C) Add a reason for the change D) Use a black pen to obliterate the entry

Assisted living facility

Which of the following is a long-term care setting? A) Acute care hospital B) Ambulatory surgery center C) Assisted living facility D) Community mental health center

Only abbreviations approved by the healthcare organization can be used

Which of the following is a true statement regarding abbreviations in the health record? A) The physician can use any appropriate abbreviation in the health record B) Only abbreviations approved by the state can be used C) Only abbreviations approved by Medicare can be used D) Only abbreviations approved by the healthcare organization can be used

Documents imaging

Which of the following is an electronic record technological capability that allows a paper-based x-ray report to be accessed? A) Database management B) Documents imaging C) Text processing D) Vocabulary standards

Notice of Privacy Practices

Which of the following is an example of an acknowledgement? A) General consent to treat document B) Consultation report C) Notice of privacy practices D) Patient instructions document

Ambulatory surgery center (ASC)

Which of the following is an outpatient setting? A) Acute care hospital B) Ambulatory surgery center C) Assisted living facility D) Community mental health center

Medical history

Which of the following is the health record component that addresses the patient's current complaints and symptoms & lists the patient's past medical, personal, & family history? A) Medical history B) Physical exam C) Clinical observation D) Problem list

Time and means of the patient's arrival

Which of the following materials is documented in an emergency care record? A) Time and means of the patient's arrival B) APGAR C) Minimum Data set D) Patient's complete medical history & physical

It documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

Which of the following statements justifies the need for a consultation report? A) It provides a chronological summary of the patient's medical history & illness B) It documents the physician's instructions to other parties involved in providing care to a patient C) It documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care D) It concisely summarizes the patient's treatment & stay in the hospital from the time of admission to the time of discharge

Subacute care

Which of the following types of facilities is generally governed by long-term care documentation standards? A) Ambulatory surgical center B) Rehabilitation C) Subacute care D) Behavioral health