Which 2 major types of data are contained in the health record?
Administrative & clinical
Which of the following terms refers to state or county regulations that healthcare facilities must meet to be permitted to provide care?
Licensure
Which of the following would NOT be found in a medical history?
Vital signs
An attending physician requests the advice of a second physician who then reviews the health record & examines the patient. The second physician records impressions in what type of report?
Consultation
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
Care plan
Written or spoken permission to proceed with care is calssified as?
Expressed consent
Which of the following reports provides information on tissue remove during a procedure?
Pathology report
Sleeping patterns, head & chest measurements, feeding & elimination status, weight, and Apgar scores are recorded in which of following records?
newborn
Which of the following is not considered patient demographic information?
Admitting diagnosis
Which of the following administrative documents names the patients choice of legal representative for healthcare purposes?
Advance directive
Which type of health record contains information about care provided prior to arrival at a healthcare setting & documentation of care provided to stabilize the patient?
Emergency care
Patient history questionnaires, problem lists, diagnostic test results, & immunization records are commonly found in which type of record?
Ambulatory care
The ambulatory surgery record contains information most similar to?
Hospital operative records
Which standardized tool is used to assess Medicare-certified rehab facilities?
Patietn assessment instrument (PAI)
Interdisciplinary care plan are an important part of which type of health record?
Hospice care
Portions of a treatment record may be maintained in a patients home in which 2 types of settings?
Home health & end-stage renal disease
A patients legal status, complaints of others regarding the patient, & reports of restraints or seclusion would be found most frequently in which type of health record?
Behavioral health
Paper records may require thinning in which 2 settings?
Long-term care & correctional services
A growth & development record may be found in what type of record?
Pediatric
The document that indicates current & past medical conditons is?
Problem list
Which of the following is an accrediting organization?
DNV
An accrediting organizaiton is awarded deemed status by Medicare. This means that facilities receiving accreditaiton under its guidelines do not need to?
Undergo Medicare certification surveys
Which group focuses on accreditation of managed care & preferred provider organizations?
National Committee for Quality Assurance
Which of the following regulations would most likely contain information on who is authorized to enter documentation in a patients record?
Facility rules & regulations
Which of the following groups has instituted a health record-prohibited abbreviation lsit?
Joint commission on Accreditation of healthcare organizations
Which tupe of health record includes both paper & computerized components?
Hybrid
Which of the following is a disadvantage of an EHR over a paper-based record?
Requires privacy & security measures
In an integrated health record, documentation by health professionals is organized?
Intermized in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded?
Subjective
Which of the following electronic record technological capabilities would allow an x-ray to be sent to a phsyciain in another state?
Image processing
Which of the following is true of paper-based records?
They are susceptible to damage from fire or floods
A definition of what constitutes a record, recording where each component is located & noting dates of format changes are particularly important in?
Hybrid records
In a problem-oriented health record, problems are organized by?
Number
Health level Seven (HL7) has developed guidelines that address which aspect of the electronic record?
Definition of functions
Which type of dat input mechanism is commonly used in both paper & electronic environment?
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