Health Info Systems Chapter 3

Which type of standard is required of hospitals by states prior to providing any healthcare?
Licensure
Which of the following clinical data elements is not usually documented in the acute-care health record?
Records of immunizations
Which of the following is not a function of the discharge summary?
Providing information about the patient’s insurance coverage
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?
Laboratory findings
Which of the following would not be considered clinical data?
Name of insurance company
Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?
The Health Insurance Portability and Accountability Act
Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?
Operative report
Which of the following materials is not documented in an emergency care record?
Patient’s complete medical history
Which of the following types of facility is not generally governed by long-term care documentation standards?
Assisted living facilities
Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?
Outcomes and Assessment Information Set
Which regulations are most commonly applied in end-stage renal disease treatment?
Medicare Conditions for Coverage
Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?
The incorrect information should be obliterated.
Which of the following types of healthcare facilities may seek accreditation from the Joint Commission?
Acute care hospitals, Psychiatric hospitals, Home care providers, Ambulatory care organizations
The federal Conditions of Participation apply to which type of healthcare organizations?
Organizations that treat Medicare or Medicaid patients
Which of the following is not a traditional health record format?
Process-oriented health record
Which health record format is most commonly used by healthcare settings as they transition to electronic records?
Hybrid records
Which of the following is an example of administrative information?
The patient’s address
The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is:
Plan
“Acute allergic reaction” would be documented in which part of a SOAP note?
Assessment
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?
Accreditation
Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) _________ paper record.
Integrated
Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient’s own words?
Chief complaint
Which of the following creates a chronological report of the patient’s condition and response to treatment during a hospital stay?
Progress notes
Which of the following determines who can receive and transcribe verbal orders?
Medical staff bylaws
The health record is the legal document that provides evidence of the
interventions of healthcare professionals.
Electronic health record is the most widely used term by
federal government and other entities.
Clinical data is the patient’s
medical condition, diagnosis, procedures performed as well as healthcare treatment provided.
Administrative data includes
demographic and financial info, consents and authorizations.
Four main standards for documentation:
Facility specific, licensure, certification, accrediation
Facility specific-
found in the facility policies and procedures
Licensure-
must be licensed by government entities before can provide services
Certification-
government reimbursement program standards are applied to facilities that participate in Medicare and Medicaid
Accreditation-
end result of an intensive external review process that indicates a facility has voluntarily met the standards
Acute care records do not contain
immunization records
Ambulatory care is provided in
doctor’s office, clinics, outpatient and urgent care settings
Long-term care are governed by both
federal and state regulations
Basic principles of health record documentation:
Uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency and format
Source oriented record have the documents grouped together according to their
point of origin
Problem oriented record is better suited to
serve the patient and the end user of the patient information.
Key characteristic is itemized list of the patient’s
past and present social, psychological and medical problems.
Each progress note is labeled with
unique number assigned to the problem.
Integrated records are arranged so the documentation from various sources is
intermingled and follows strict chronological order
Key Capabilities of an Electronic Health Record System and its 8 core functions:
health information and data,
result management,
order management,
decision support,
electronic communication and connectivity,
patient support,
administrative processes and reporting,
Reporting and population health.

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