Question 1

The health unit coordinator (HUC)would view the patient's chart as primarily:

Accepted Answer

A) a means of communication between the doctor and the hospital staff. 
B) a means of billing the insurance company. 
C) material for medical fiction books. 
D) interesting reading for staff members. 
A) a means of communication between the doctor and the hospital staff. 
B) a means of billing the insurance company. 
C) material for medical fiction books. 
D) interesting reading for staff members. A

Question 2

The patient is receiving medication because his blood sugar is regularly too high.The nurse is required to check his blood sugar at regular intervals.When paper charts are used,this information will be written on the:

Accepted Answer

A) parenteral fluid or infusion record. 
B) therapy record. 
C) diabetic record. 
D) anticoagulant therapy record. 
A) parenteral fluid or infusion record. 
B) therapy record. 
C) diabetic record. 
D) anticoagulant therapy record. C

Question 3

When the EMR with computerized physician order entry (CPOE)is used,an error in treatment:

Accepted Answer

A) must be documented in the patient's EMR and an incident report must be completed. 
B) must be documented on an incident report but may be deleted from the EMR. 
C) may be deleted from the EMR,and an incident report is not necessary. 
D) must be documented in the patient's EMR,but an incident report is not necessary. 
A) must be documented in the patient's EMR and an incident report must be completed. 
B) must be documented on an incident report but may be deleted from the EMR. 
C) may be deleted from the EMR,and an incident report is not necessary. 
D) must be documented in the patient's EMR,but an incident report is not necessary. A

Question 4

A patient's chart is labeled with name alert when:

Accepted Answer

A) a patient has celebrity status. 
B) a patient is an employee of the hospital. 
C) two patients on a nursing unit have similarly spelled last names (or the same name). 
D) a patient's name is similar to his or her doctor's name. 
A) a patient has celebrity status. 
B) a patient is an employee of the hospital. 
C) two patients on a nursing unit have similarly spelled last names (or the same name). 
D) a patient's name is similar to his or her doctor's name.

Question 5

A patient who refuses a blood transfusion would be asked to:

Accepted Answer

A) sign a refusal to permit blood transfusion. 
B) change their mind. 
C) talk to a psychiatrist. 
D) sign a consent to receive a blood transfusion. 
A) sign a refusal to permit blood transfusion. 
B) change their mind. 
C) talk to a psychiatrist. 
D) sign a consent to receive a blood transfusion.

Question 6

Guidelines for entering information into the patient's EMR include:

Accepted Answer

A) All nurses' notes must be scanned into the patient's EMR. 
B) The HUC must type all doctors' orders into the patient's EMR. 
C) The HUC must scan all handwritten doctors' orders into the patient's EMR. 
D) Handwritten progress notes,electrocardiograms (EKGs),and outside records and reports must be scanned into the patient's EMR. 
A) All nurses' notes must be scanned into the patient's EMR. 
B) The HUC must type all doctors' orders into the patient's EMR. 
C) The HUC must scan all handwritten doctors' orders into the patient's EMR. 
D) Handwritten progress notes,electrocardiograms (EKGs),and outside records and reports must be scanned into the patient's EMR.

Question 7

A locked workstation that is located on the wall outside a patient's room is called a:

Accepted Answer

A) pen tab. 
B) WALLaroo. 
C) WALKaroo. 
D) cluster of workstations (COW). 
A) pen tab. 
B) WALLaroo. 
C) WALKaroo. 
D) cluster of workstations (COW).

Question 8

For patients who receive physical therapy,notes regarding their progress would be recorded on the:

Accepted Answer

A) therapy record. 
B) doctors' progress notes. 
C) nurses' progress notes. 
D) consultation form. 
A) therapy record. 
B) doctors' progress notes. 
C) nurses' progress notes. 
D) consultation form.

Question 9

Supplemental forms are placed in a patient's paper chart when:

Accepted Answer

A) the patient's doctor requests them. 
B) specific conditions or events dictate their use. 
C) the nurse determines that they are necessary. 
D) the HIMS department requires their use. 
A) the patient's doctor requests them. 
B) specific conditions or events dictate their use. 
C) the nurse determines that they are necessary. 
D) the HIMS department requires their use.

Question 10

A parenteral fluid record is placed in a patient's chart when the patient is:

Accepted Answer

A) receiving medication. 
B) receiving IV fluids. 
C) recovering from surgery. 
D) having his or her vital signs taken frequently. 
A) receiving medication. 
B) receiving IV fluids. 
C) recovering from surgery. 
D) having his or her vital signs taken frequently.

Question 11

If you see 2400 noted in a patient's chart as the time when a patient was given a drug,this means that:

Accepted Answer

A) the nurse was obviously sidetracked,because this does not refer to any time. 
B) it has been 24 hours since the patient was last given the drug. 
C) the patient was given the drug at noon. 
D) the drug was given at midnight,and this was recorded using military time. 
A) the nurse was obviously sidetracked,because this does not refer to any time. 
B) it has been 24 hours since the patient was last given the drug. 
C) the patient was given the drug at noon. 
D) the drug was given at midnight,and this was recorded using military time.

Question 12

A patient's old record refers to:

Accepted Answer

A) a senior citizen's record that exceeds 10 years of age. 
B) calling the patient's doctor to obtain date(s)of previous admission(s). 
C) asking the patient to provide date(s)of previous admission(s). 
D) calling or sending a request to HIMS to obtain the patient's records from a previous admission. 
A) a senior citizen's record that exceeds 10 years of age. 
B) calling the patient's doctor to obtain date(s)of previous admission(s). 
C) asking the patient to provide date(s)of previous admission(s). 
D) calling or sending a request to HIMS to obtain the patient's records from a previous admission.

Question 13

Which of the following abbreviations may be noted on the patient's medication administration record (MAR)?

Accepted Answer

A) Hx 
B) H&P 
C) DRG 
D) NKDA 
A) Hx 
B) H&P 
C) DRG 
D) NKDA

Question 14

Charting vital signs and other data accurately and in a timely manner is important so the information is readily available to:

Accepted Answer

A) the patient's case manager. 
B) the patient's family. 
C) the incoming HUC. 
D) the patient's doctor. 
A) the patient's case manager. 
B) the patient's family. 
C) the incoming HUC. 
D) the patient's doctor.

Question 15

When military time is used to enter a notation on a patient's chart,12:30 AM is written:

Accepted Answer

A) 1230. 
B) 2030. 
C) 2230. 
D) 2430. 
A) 1230. 
B) 2030. 
C) 2230. 
D) 2430.

Question 16

When thinning a chart,it is acceptable practice to:

Accepted Answer

A) send thinned out chart forms to the health information management system department (HIMS)prior to the patient's discharge. 
B) discard or shred selected records from the earliest part of the admission. 
C) transfer thinned out records with the patient's chart if the patient is sent to another unit. 
D) place thinned out records into another binder alongside the current record in the chart rack. 
A) send thinned out chart forms to the health information management system department (HIMS)prior to the patient's discharge. 
B) discard or shred selected records from the earliest part of the admission. 
C) transfer thinned out records with the patient's chart if the patient is sent to another unit. 
D) place thinned out records into another binder alongside the current record in the chart rack.

Question 17

Anna Jensen and Anna Johnson are both patients on the nursing unit.While stuffing Anna Jensen's chart,the HUC mistakenly used Anna Johnson's ID labels to label the forms.No specific patient information appears on these mislabeled forms.What should the HUC do to correct the error?

Accepted Answer

A) Complete an incident report because this error falls outside of the norm for this task. 
B) Once it has been established that no patient information is noted on the forms,the incorrectly stamped forms may be shredded. 
C) Place correct ID labels over the incorrect labels,and reuse the forms. 
D) Peel off the ID labels as much as possible,and once the labels are removed,the form may be reused. 
A) Complete an incident report because this error falls outside of the norm for this task. 
B) Once it has been established that no patient information is noted on the forms,the incorrectly stamped forms may be shredded. 
C) Place correct ID labels over the incorrect labels,and reuse the forms. 
D) Peel off the ID labels as much as possible,and once the labels are removed,the form may be reused.

Question 18

Which of the following would be legal to write on a patient's surgical consent form?

Accepted Answer

A) Lumpectomy lt breast 
B) Removal of a lump from lt breast 
C) Lt breast lumpectomy 
D) Lumpectomy left breast 
A) Lumpectomy lt breast 
B) Removal of a lump from lt breast 
C) Lt breast lumpectomy 
D) Lumpectomy left breast

Question 19

A patient's height and weight will be found on which chart form?

Accepted Answer

A) Admission and service agreement form 
B) Face sheet 
C) CQI 
D) Nurses' admission record 
A) Admission and service agreement form 
B) Face sheet 
C) CQI 
D) Nurses' admission record

Question 20

Guidelines for writing on a patient's paper chart include which of the following?

Accepted Answer

A) Entries may be made in pen or pencil. 
B) A written error made on a patient chart form may be erased or obliterated. 
C) All written entries on patient chart forms must include the date and time. 
D) The HUC may rewrite doctors' orders if the doctor's handwriting is difficult to read. 
A) Entries may be made in pen or pencil. 
B) A written error made on a patient chart form may be erased or obliterated. 
C) All written entries on patient chart forms must include the date and time. 
D) The HUC may rewrite doctors' orders if the doctor's handwriting is difficult to read.

Exam 8: The Patients Chart or Electronic Medical Record

The health unit coordinator (HUC)would view the patient's chart as primarily:

The patient is receiving medication because his blood sugar is regularly too high.The nurse is required to check his blood sugar at regular intervals.When paper charts are used,this information will be written on the:

When the EMR with computerized physician order entry (CPOE)is used,an error in treatment:

A patient's chart is labeled with name alert when:

A patient who refuses a blood transfusion would be asked to:

Guidelines for entering information into the patient's EMR include:

A locked workstation that is located on the wall outside a patient's room is called a:

For patients who receive physical therapy,notes regarding their progress would be recorded on the:

Supplemental forms are placed in a patient's paper chart when:

A parenteral fluid record is placed in a patient's chart when the patient is:

If you see 2400 noted in a patient's chart as the time when a patient was given a drug,this means that:

A patient's old record refers to:

Which of the following abbreviations may be noted on the patient's medication administration record (MAR)?

Charting vital signs and other data accurately and in a timely manner is important so the information is readily available to:

When military time is used to enter a notation on a patient's chart,12:30 AM is written:

When thinning a chart,it is acceptable practice to:

Anna Jensen and Anna Johnson are both patients on the nursing unit.While stuffing Anna Jensen's chart,the HUC mistakenly used Anna Johnson's ID labels to label the forms.No specific patient information appears on these mislabeled forms.What should the HUC do to correct the error?

Which of the following would be legal to write on a patient's surgical consent form?

A patient's height and weight will be found on which chart form?

Guidelines for writing on a patient's paper chart include which of the following?

Health Unit Coordinating

Overview of Health Care Today

The Nursing Department and Medical Staff

Communication Devices and Their Uses

Communication and Interpersonal Skills

Workplace Behavior

Management Techniques and Problem Solving Skills for Health Unit Coordinating

Health Unit Coordinator Role in Processing of Electronic, preprinted, and Handwritten Doctors Orders

Patient Activity, patient Positioning, and Nursing Observation Orders

Nursing Intervention or Treatment Orders

Nutritional Care Orders

Medication Orders

Laboratory Orders

Diagnostic Imaging Orders

Other Diagnostic Studies

Treatment Orders

Miscellaneous Orders

Admission,preoperative,and Postoperative Procedures

Discharge, transfer, and Postmortem Procedures

Reports, infection Control, emergencies, and Special Services

Medical Terminology, basic Human Structure, and Disorders

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