HIT Chapter 3 Review

Which two major types of data are contained in the health record? A. Nursing and physician B. Administrative and clinical C. Demographic and financial D. Surgical and medical

Which of the following terms refers to state or county regulations that healthcare facilities must meet to be permitted to provide care? A. Accreditation B. Bylaws C. Certification D. Licensure

Which of the following is an accrediting organization? A. State regulating agencies B. American Health Information Management Association C. Det Norske Veritas Healthcare D. Centers for Medicare and Medicaid Services

An accrediting organization is awarded deemed status by Medicare for one of its programs. This means that facilities receiving accreditation under its guidelines do not need to: A. Meet licensure standards B. Undergo Medicare certification surveys C. Undergo accreditation surveys D. Meet Medicare certification standards

Which group focuses on accreditation of managed care? A. Accreditation Association for Ambulatory Healthcare B. National Committee for Quality Assurance C. Commission on Accreditation of Rehabilitation Facilities D. The Joint Commission

Which group focuses on accreditation of rehabilitation programs and services? A. CARF B. AOA C. AAAHC D. HFAP

Which of these accreditation organizations provides standards for the widest variety of healthcare facilities? A. American Correctional Association B. The Joint Commission C. Accreditation Commission for Health Care D. American Osteopathic Association

Which of the following would not be found in a medical history? A. Chief complaint B. Vital signs C. Present illness D. Review of systems

An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report? A. Consultation B. Progress note C. Operative report D. Discharge summary

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? A. Flow record B. Vital signs record C. Care plan D. Surgical note

Written or spoken permission to proceed with care is classified as: A. Expressed consent B. Acknowledgment C. Advance directive D. Implied consent

Which of the following reports provides information on tissue removed during a procedure? A. Operative report B. Laboratory report C. Pathology report D. Anesthesia report

Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records? A. Obstetric B. Newborn C. Surgical D. Emergency

Which of the following is not considered patient demographic information? A. Patient's date of birth B. Name of next of kin C. Type of admission D. Admitting diagnosis

Which of the following administrative documents provides information on the patient's desires for healthcare for use if he/she is incapacitated? A. Advance directive B. Patient's bill of rights C. Notice of privacy practices D. Authorization for release of information

Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient? A. Ambulatory care B. Emergency care C. Long-term care D. Rehabilitative care

Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record? A. Ambulatory care B. Emergency care C. Long-term care D. Rehabilitative care

The ambulatory surgery record contains information most similar to: A. Physician's office records B. Emergency care records C. Hospital operative records D. Hospital obstetric records

Which standardized tool is used to assess Medicare-certified rehabilitation facilities? A. Outcomes and Assessment Information Set (OASIS) B. Care area assessment (CAA) C. Patient assessment instrument (PAI) D. Minimum Data Set (MDS)

Interdisciplinary care plans are an important part of which type of health record? A. Emergency department B. Ambulance C. End-stage renal disease D. Ambulatory care

Portions of a treatment record may be maintained in a patient's home in which two types of settings? A. Hospice and behavioral health B. Home health and hospice C. Obstetric and gynecologic care D. Rehabilitation and correctional care

A patient's legal status, complaints of others regarding the patient, and reports of restraints or seclusion would be found most frequently in which type of health record? A. Rehabilitative care B. Ambulatory care C. Behavioral health D. Personal health

Paper records may require thinning in which two settings? A. Home health and hospice B. Rehabilitation and end-stage renal disease C. Ambulatory care and behavioral health D. Long-term care and correctional services

A growth and development record may be found in what type of record? A. Rehabilitative care B. Pediatric C. Behavioral health D. Obstetric

The document that indicates current and past medical conditions is: A. MDS B. CAAs C. Problem list D. PAI

Which type of health record includes both paper and electronic components? A. Hybrid B. Electronic C. Problem-oriented D. Source-oriented

Which of the following is a disadvantage of an EHR over a paper-based record? A. Allows customization to user needs B. Permits multiple users at the same time C. Enables duplicate copies to be made easily D. Requires privacy and security measures

In an integrated health record, documentation by health professionals is organized: A. In sections by type of professional B. In sections by problem number C. Intermixed in date sequence D. Depends on facility policy

The patient indicates that her pain is worse. In which part of a SOAP note would this information be recorded? A. Subjective B. Objective C. Assessment D. Plan

Which of the following electronic record technological capabilities would allow an x-ray to be sent to a physician in another state? A. Database management B. Image processing C. Text processing D. Vocabulary standards

Which of the following is true of paper-based records? A. They are susceptible to damage from fire or floods. B. They lack standardization. C. They are easy to access and update. D. They require a limited number of personnel to process.

A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in: A. Electronic records B. Integrated records C. Paper records D. Hybrid records

In a problem-oriented health record, problems are organized by: A. Letter B. Number C. Patient name D. Body system