Question 1

Match between columns
                        Premises: Chronological record of care administered

Accepted Answer

The Answer of Medical history and Diagnostic tests and Graphics is...

Question 2

Which of the following methods is appropriate for disposing of documents that contain confidential patient information?

Accepted Answer

A)  Office waste basket, as long as the room is secure 
B)  Hazardous waste bag 
C)  Burning 
D)  Facility waste container, such as a dumpster 
A)  Office waste basket, as long as the room is secure 
B)  Hazardous waste bag 
C)  Burning 
D)  Facility waste container, such as a dumpster C

Question 3

Match between columns
                        Premises: Complete personal, familial, and social information

Accepted Answer

The Answer of Medical history and Physician's orders and Progress is...

Question 4

Which of the following statements are true about personal health records (PHR)?

Accepted Answer

A)  Include an assessment of body systems 
B)  Computerized information used by health care systems 
C)  Required by law 
D)  Documents are created and maintained by the individual 
A)  Include an assessment of body systems 
B)  Computerized information used by health care systems 
C)  Required by law 
D)  Documents are created and maintained by the individual

Question 5

Faxes are a good way to efficiently send patient records to another provider.

Accepted Answer

A) True 
 B)False

Question 6

Which of the following personnel may write progress notes that are included in the patient's official medical record?

Accepted Answer

A)  Only physicians 
B)  Only nurses 
C)  Only physicians and nurses 
D)  Any health care professional who provides a direct service to the patient 
A)  Only physicians 
B)  Only nurses 
C)  Only physicians and nurses 
D)  Any health care professional who provides a direct service to the patient

Question 7

A good way for health care professionals to increase their efficiency is to gather all the records for patients to be seen that day and prepare the written documentation in advance for procedures to be done during the day.

Accepted Answer

A) True 
 B)False

Question 8

Match between columns
                        Premises: Medications and treatments that have been prescribed

Accepted Answer

The Answer of Physician's orders and Progress notes and Graphics is...

Question 9

What is the best way to record in a patient's report that he only slept from about 1:00 a.m. to 4:30 a.m.?

Accepted Answer

A)  Patient reports difficulty sleeping. 
B)  Patient is sleeping poorly. 
C)  Patient states, "I only slept 3 ½ hours last night." 
D)  Patient needs help sleeping. 
A)  Patient reports difficulty sleeping. 
B)  Patient is sleeping poorly. 
C)  Patient states, "I only slept 3 ½ hours last night." 
D)  Patient needs help sleeping.

Question 10

Match between columns
                        Premises: Reason the patient seeks medical care

Accepted Answer

The Answer of Charting and Medical documentation and Chief complaint is...

Question 11

Match between columns
                        Premises: Results of X-rays, electrocardiograms (ECG or EKG), and blood tests

Accepted Answer

The Answer of Medical history and Progress notes and Diagnostic is...

Question 12

An example of a chief complaint would be when the health care provider notes an increase in blood pressure that requires treatment.

Accepted Answer

A) True 
 B)False

Question 13

When using the method known as "charting by exception," only __________ findings are noted.

Accepted Answer

The answer of When using the method known as "charting...

Question 14

Flow sheets are forms for specialty needs.

Accepted Answer

A) True 
 B)False

Question 15

Match between columns
                        Premises: Visual format for recording measurements such as blood pressure

Accepted Answer

The Answer of Medical history and Physician's orders and Progress is...

Question 16

Match between columns
                        Premises: Opinions of a health care professional about the nature of the patient's problem

Accepted Answer

The Answer of Assessment and Medical record and Charting and is...

Question 17

Medical documentation that is  _____________ illegibly is useless and may cause legal problems.

Accepted Answer

The answer of Medical documentation that is  _____________ illegibly is...

Question 18

Comprehensive systems for maintaining computerized patient records are fairly inexpensive to purchase and implement.

Accepted Answer

A) True 
 B)False

Question 19

Match between columns
                        Premises: All notes added to a patient's medical record

Accepted Answer

The Answer of Assessment and Charting and Medical documentation and is...

Question 20

A coworker calls from home and asks you to sign his name on a patient chart that he forgot to sign after administering a medication. What should you do?

Accepted Answer

A)  Sign his name. 
B)  Sign your name. 
C)  Sign both your names. 
D)  Refuse to sign either name. 
A)  Sign his name. 
B)  Sign your name. 
C)  Sign both your names. 
D)  Refuse to sign either name.

Which of the following methods is appropriate for disposing of documents that contain confidential patient information?

Which of the following statements are true about personal health records (PHR)?

Faxes are a good way to efficiently send patient records to another provider.

Which of the following personnel may write progress notes that are included in the patient's official medical record?

A good way for health care professionals to increase their efficiency is to gather all the records for patients to be seen that day and prepare the written documentation in advance for procedures to be done during the day.

What is the best way to record in a patient's report that he only slept from about 1:00 a.m. to 4:30 a.m.?

An example of a chief complaint would be when the health care provider notes an increase in blood pressure that requires treatment.

When using the method known as "charting by exception," only __________ findings are noted.

Flow sheets are forms for specialty needs.

Medical documentation that is _____________ illegibly is useless and may cause legal problems.

Comprehensive systems for maintaining computerized patient records are fairly inexpensive to purchase and implement.

A coworker calls from home and asks you to sign his name on a patient chart that he forgot to sign after administering a medication. What should you do?

Your Career in Health Care

Health Care Yesterday, Today, and Tomorrow

Ethical and Legal Responsibilities

Medical Terminology

Medical Math

Organization of the Human Body

Structure and Function of the Human Body

Growth and Development

Body Mechanics

Infection Control

Environmental Safety

Lifestyle Management

Professionalism

Professional Development and Lifelong Learning

The Patient As an Individual

The Communication Process

Written Communication

Computers and Technology in Health Care

Physical Assessment

Emergency Procedures

Paying for Health Care

Quality Control and Customer Service

Job Leads and the Résumé

Interview Portfolio and Application

Successful Employment Strategies

Filters

Exam 19: Documentation and Medical Records

Which of the following methods is appropriate for disposing of documents that contain confidential patient information?

Which of the following statements are true about personal health records (PHR)?

Faxes are a good way to efficiently send patient records to another provider.

Which of the following personnel may write progress notes that are included in the patient's official medical record?

A good way for health care professionals to increase their efficiency is to gather all the records for patients to be seen that day and prepare the written documentation in advance for procedures to be done during the day.

What is the best way to record in a patient's report that he only slept from about 1:00 a.m. to 4:30 a.m.?

An example of a chief complaint would be when the health care provider notes an increase in blood pressure that requires treatment.

When using the method known as "charting by exception," only __________ findings are noted.

Flow sheets are forms for specialty needs.

Medical documentation that is _____________ illegibly is useless and may cause legal problems.

Comprehensive systems for maintaining computerized patient records are fairly inexpensive to purchase and implement.

A coworker calls from home and asks you to sign his name on a patient chart that he forgot to sign after administering a medication. What should you do?

Your Career in Health Care

Health Care Yesterday, Today, and Tomorrow

Ethical and Legal Responsibilities

Medical Terminology

Medical Math

Organization of the Human Body

Structure and Function of the Human Body

Growth and Development

Body Mechanics

Infection Control

Environmental Safety

Lifestyle Management

Professionalism

Professional Development and Lifelong Learning

The Patient As an Individual

The Communication Process

Written Communication

Computers and Technology in Health Care

Physical Assessment

Emergency Procedures

Paying for Health Care

Quality Control and Customer Service

Job Leads and the Résumé

Interview Portfolio and Application

Successful Employment Strategies

Filters