Question 1

The quality improvement committee wants to determine the number of patients admitted with a fever. The quickest way to locate this information would be to review the

Accepted Answer

A)   admission history and physicals.
B)   face sheets.
C)   input/output records.
D)   nursing assessments.

Question 2

An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the

Accepted Answer

A)   preadmission testing.
B)   primary provider.
C)   principal procedure.
D)   provisional diagnosis.

Question 3

Health care facilities must establish record retention schedules. Summarize the purpose of a record retention schedule.

Accepted Answer

The purpose of a record retent...

Question 4

To determine the ____________________, divide the total number of delinquent records by the number of discharges in the period.

Accepted Answer

delinquent...

Question 5

The Joint Commission requires that patient records be completed within 20 days after a patient is discharged.

Accepted Answer

A) True 
 B)False

Question 6

Sally Jones is responsible for analyzing, organizing, and presenting information based on patient records. This is a function of:

Accepted Answer

A)   data capture
B)   information capture
C)   information generation
D)   report generation

Question 7

Computer systems have changed the functions and role of health information professionals.

Accepted Answer

A) True 
 B)False

Question 8

Dr. Jones records the following information in the ____ section of a patient's SOAP note: BP is 120/74. Temperature is 100°F. Upon examination, lungs are clear but patient has nasal congestion.

Accepted Answer

A)   assessment
B)   objective
C)   plan
D)   subjective

Question 9

When an individual is admitted as a hospital inpatient, past records are frequently retrieved to provide for continuity of care.

Accepted Answer

A) True 
 B)False

Question 10

Pre- and postanesthesia evaluations would be found in a(n)  ____ record.

Accepted Answer

A)   ambulatory care
B)   behavioral health care
C)   long-term care
D)   surgical care

Question 11

Health care providers are responsible for documenting care and treatment to prove that patient care was provided.

Accepted Answer

A) True 
 B)False

Question 12

Initials of care providers are typically used to authenticate entries on

Accepted Answer

A)   admission assessments and histories.
B)   discharge summaries.
C)   flow sheets and medication records.
D)   operative reports.

Question 13

Since the early 1980s, the provision of outpatient services has decreased.

Accepted Answer

A) True 
 B)False

Question 14

Demographic data is a type of clinical data that identifies a patient's medical condition.

Accepted Answer

A) True 
 B)False

Question 15

The use of signature stamps should be specified in the

Accepted Answer

A)   administrative policies.
B)   hospital bylaws.
C)   medical staff bylaws.
D)   nursing policies.

Exam 4: The Patient Record: Hospital, Physician Office, and Alternate Care Settings

Health care facilities must establish record retention schedules. Summarize the purpose of a record retention schedule.

Correct Answer
verified
The purpose of a record retent...
View Answer

Health care providers are responsible for documenting care and treatment to prove that patient care was provided.

Correct Answer
verified

Initials of care providers are typically used to authenticate entries on

Correct Answer
verified

Dr. Jones records the following information in the ____ section of a patient's SOAP note: BP is 120/74. Temperature is 100°F. Upon examination, lungs are clear but patient has nasal congestion.

Correct Answer
verified

Since the early 1980s, the provision of outpatient services has decreased.

Correct Answer
verified

The quality improvement committee wants to determine the number of patients admitted with a fever. The quickest way to locate this information would be to review the

Correct Answer
verified

An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the

Correct Answer
verified

Pre- and postanesthesia evaluations would be found in a(n) ____ record.

Correct Answer
verified

Sally Jones is responsible for analyzing, organizing, and presenting information based on patient records. This is a function of:

Correct Answer
verified

The Joint Commission requires that patient records be completed within 20 days after a patient is discharged.

Correct Answer
verified

Demographic data is a type of clinical data that identifies a patient's medical condition.

Correct Answer
verified

When an individual is admitted as a hospital inpatient, past records are frequently retrieved to provide for continuity of care.

Correct Answer
verified

To determine the ____________________, divide the total number of delinquent records by the number of discharges in the period.

Correct Answer
verified
delinquent...
View Answer

The use of signature stamps should be specified in the

Correct Answer
verified

Computer systems have changed the functions and role of health information professionals.

Correct Answer
verified

Exam 4: The Patient Record: Hospital, Physician Office, and Alternate Care Settings

Health care facilities must establish record retention schedules. Summarize the purpose of a record retention schedule.

Correct AnswerverifiedThe purpose of a record retent...View AnswerShow Answer

Health care providers are responsible for documenting care and treatment to prove that patient care was provided.

Correct AnswerverifiedShow Answer

Initials of care providers are typically used to authenticate entries on

Correct AnswerverifiedShow Answer

Dr. Jones records the following information in the ____ section of a patient's SOAP note: BP is 120/74. Temperature is 100°F. Upon examination, lungs are clear but patient has nasal congestion.

Correct AnswerverifiedShow Answer

Since the early 1980s, the provision of outpatient services has decreased.

Correct AnswerverifiedShow Answer

The quality improvement committee wants to determine the number of patients admitted with a fever. The quickest way to locate this information would be to review the

Correct AnswerverifiedShow Answer

An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the

Correct AnswerverifiedShow Answer

Pre- and postanesthesia evaluations would be found in a(n) ____ record.

Correct AnswerverifiedShow Answer

Sally Jones is responsible for analyzing, organizing, and presenting information based on patient records. This is a function of:

Correct AnswerverifiedShow Answer

The Joint Commission requires that patient records be completed within 20 days after a patient is discharged.

Correct AnswerverifiedShow Answer

Demographic data is a type of clinical data that identifies a patient's medical condition.

Correct AnswerverifiedShow Answer

When an individual is admitted as a hospital inpatient, past records are frequently retrieved to provide for continuity of care.

Correct AnswerverifiedShow Answer

To determine the ____________________, divide the total number of delinquent records by the number of discharges in the period.

Correct Answerverifieddelinquent...View AnswerShow Answer

The use of signature stamps should be specified in the

Correct AnswerverifiedShow Answer

Computer systems have changed the functions and role of health information professionals.

Correct AnswerverifiedShow Answer

Correct Answer
verified
The purpose of a record retent...
View Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
delinquent...
View Answer

Correct Answer
verified

Correct Answer
verified