Question 1

In a paper record, the admission record is often synonymous with the:

Accepted Answer

A)  History and physical 
B)  Nursing assessment 
C)  Face sheet 
D)  Demographic data 
A)  History and physical 
B)  Nursing assessment 
C)  Face sheet 
D)  Demographic data

Question 2

Compare and contrast the physician's SOAP strategy of documentation with the nursing strategy of documentation. Why are they different?

Accepted Answer

Responses should focus on the physician'

Question 3

If a health care professional is working under the supervision of another, such as a resident being supervised by an attending physician, then the notes written by that professional must be _________________ by the supervisor.

Accepted Answer

The answer of If a health care professional is working...

Question 4

Match between columns
                        Premises: Maintained in system files
Nurse/nursing staff
Patient registration
Attending physician (or his/her designee)

Accepted Answer

The Answer of discharge summary and health care facility identification is...

Question 5

The best place to find the medications administered during an operation is:

Accepted Answer

A)  Physician's orders 
B)  Operative report 
C)  Nursing medication administration record 
D)  Anesthesia record 
A)  Physician's orders 
B)  Operative report 
C)  Nursing medication administration record 
D)  Anesthesia record

Question 6

If there is one physical location within the hospital for all patient registration activities, the registration function is said to be:

Accepted Answer

A)  Centralized 
B)  Decentralized 
C)  Admissions 
D)  Departmental 
A)  Centralized 
B)  Decentralized 
C)  Admissions 
D)  Departmental

Question 7

In order to ____________ a document or other data collection device, a physician may sign the document or enter a password.

Accepted Answer

The answer of In order to ____________ a document or...

Question 8

During registration, the patient signs a(n) _____________ to grant the hospital permission to provide general diagnostic and therapeutic care, as well as to release information to a third party payer.

Accepted Answer

admission

Question 9

In a patient's history, the reason the patient presented for evaluation and treatment is called the_________________ complaint.

Accepted Answer

The answer of In a patient's history, the reason the...

Question 10

Which of the following is not a necessary part of a medication record?

Accepted Answer

A)  The physician's signature 
B)  The dosage of the medication 
C)  The name of the nurse who administered the medication 
D)  The date and time of administration 
A)  The physician's signature 
B)  The dosage of the medication 
C)  The name of the nurse who administered the medication 
D)  The date and time of administration

Question 11

Records that typically incorporate physician office data into the inpatient record are _____ records.

Accepted Answer

A)  Intensive care 
B)  Neonatal 
C)  Obstetrical 
D)  Operative 
A)  Intensive care 
B)  Neonatal 
C)  Obstetrical 
D)  Operative

Question 12

Match between columns
                        Premises: The physician's documentation of a surgical procedure, usually dictated and transcribed
The process of systematically eliminating potential diagnoses. Also refers to the list of potential diagnoses
Analysis of body fluids
The physician's documentation of the examination of the patient, particularly at the initial visit
The diagnostic, therapeutic, or palliative measures that will be taken to investigate or treat the patient's condition or disease
The physician's directions regarding the patient's care. Also refers to the data collection device on which these elements are captured
Record of all drugs given to a patient during the hospitalization
Examination of a patient using x-rays
Acronym that describes the medical decision-making process. It also refers to the way physicians organize their progress notes
The nurse's evaluation of the patient
One or more surgical procedures performed at the same time
The physician's record of each visit with the patient

Accepted Answer

The Answer of Laboratory tests and Medication sheet and Progress is...

Question 13

Match between columns
                        Premises: Socioeconomic data
Financial data
Demographic data
Clinical data

Accepted Answer

The Answer of Principal diagnosis and Date of birth and is...

Question 14

In urgent situations, a physician's office may call a facility in advance to order an admission. This is called a ____________.

Accepted Answer

The answer of In urgent situations, a physician's office may...

Question 15

All of the following data are needed for a physician's verbal order EXCEPT:

Accepted Answer

A)  the nurse's authentication 
B)  the name of the patient 
C)  the time of the physician's authentication 
D)  the name of the payer or guarantor 
A)  the nurse's authentication 
B)  the name of the patient 
C)  the time of the physician's authentication 
D)  the name of the payer or guarantor

Question 16

In acute care, physician's progress notes are:

Accepted Answer

A)  Written at least daily to validate the need for care 
B)  Sometimes collected by physician residents, provided they are countersigned by the attending physician 
C)  Only collected by the attending physician 
D)  Both A and B 
A)  Written at least daily to validate the need for care 
B)  Sometimes collected by physician residents, provided they are countersigned by the attending physician 
C)  Only collected by the attending physician 
D)  Both A and B

Question 17

All of the following are elements of the UHDDS EXCEPT:

Accepted Answer

A)  Date of birth 
B)  Gender 
C)  Religion 
D)  Discharge date 
A)  Date of birth 
B)  Gender 
C)  Religion 
D)  Discharge date

Question 18

A _________ is called when an attending physician would like a specialist to review a patient case.

Accepted Answer

The answer of A _________ is called when an attending...

Question 19

Which of the following data elements is NOT likely to appear on an acute care admission record?

Accepted Answer

A)  Patient's religion 
B)  Patient's date of birth 
C)  Name of the patient's spouse 
D)  Tobacco use by the patient 
A)  Patient's religion 
B)  Patient's date of birth 
C)  Name of the patient's spouse 
D)  Tobacco use by the patient

Question 20

All of the following are typical elements of an inpatient admission record EXCEPT:

Accepted Answer

A)  Home telephone number 
B)  Religion 
C)  Insurance carrier, if any 
D)  Vital signs 
A)  Home telephone number 
B)  Religion 
C)  Insurance carrier, if any 
D)  Vital signs

In a paper record, the admission record is often synonymous with the:

Compare and contrast the physician's SOAP strategy of documentation with the nursing strategy of documentation. Why are they different?

If a health care professional is working under the supervision of another, such as a resident being supervised by an attending physician, then the notes written by that professional must be _________________ by the supervisor.

The best place to find the medications administered during an operation is:

If there is one physical location within the hospital for all patient registration activities, the registration function is said to be:

In order to ____________ a document or other data collection device, a physician may sign the document or enter a password.

During registration, the patient signs a(n) _____________ to grant the hospital permission to provide general diagnostic and therapeutic care, as well as to release information to a third party payer.

In a patient's history, the reason the patient presented for evaluation and treatment is called the_________________ complaint.

Which of the following is not a necessary part of a medication record?

Records that typically incorporate physician office data into the inpatient record are _____ records.

In urgent situations, a physician's office may call a facility in advance to order an admission. This is called a ____________.

All of the following data are needed for a physician's verbal order EXCEPT:

In acute care, physician's progress notes are:

All of the following are elements of the UHDDS EXCEPT:

A _________ is called when an attending physician would like a specialist to review a patient case.

Which of the following data elements is NOT likely to appear on an acute care admission record?

All of the following are typical elements of an inpatient admission record EXCEPT:

Health Care Delivery Systems

Collecting Health Care Data

Electronic Health Records

Health Information Management Processing

Code Sets

Reimbursement

Health Information Management Issues in Other Care Settings

Managing Health Records

Statistics

Quality and Uses of Health Information

Confidentiality and Compliance

Him Department Management

Training and Development

Filters

Exam 4: Acute Care Records

In a paper record, the admission record is often synonymous with the:

Compare and contrast the physician's SOAP strategy of documentation with the nursing strategy of documentation. Why are they different?

If a health care professional is working under the supervision of another, such as a resident being supervised by an attending physician, then the notes written by that professional must be _________________ by the supervisor.

The best place to find the medications administered during an operation is:

If there is one physical location within the hospital for all patient registration activities, the registration function is said to be:

In order to ____________ a document or other data collection device, a physician may sign the document or enter a password.

During registration, the patient signs a(n) _____________ to grant the hospital permission to provide general diagnostic and therapeutic care, as well as to release information to a third party payer.

In a patient's history, the reason the patient presented for evaluation and treatment is called the_________________ complaint.

Which of the following is not a necessary part of a medication record?

Records that typically incorporate physician office data into the inpatient record are _____ records.

In urgent situations, a physician's office may call a facility in advance to order an admission. This is called a ____________.

All of the following data are needed for a physician's verbal order EXCEPT:

In acute care, physician's progress notes are:

All of the following are elements of the UHDDS EXCEPT:

A _________ is called when an attending physician would like a specialist to review a patient case.

Which of the following data elements is NOT likely to appear on an acute care admission record?

All of the following are typical elements of an inpatient admission record EXCEPT:

Health Care Delivery Systems

Collecting Health Care Data

Electronic Health Records

Health Information Management Processing

Code Sets

Reimbursement

Health Information Management Issues in Other Care Settings

Managing Health Records

Statistics

Quality and Uses of Health Information

Confidentiality and Compliance

Him Department Management

Training and Development

Filters