CH.4 (quiz) - Health Record And Documentation . - HIM100C

Which of the following is not usually a component of acute care patient records?

The attending physician is responsible for which of the following types of acute- care documentation?

Which of the following is an example of clinical data?

A nurse is responsible for which of the following types of acute care documentation?

The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the:

Specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?

Documentation standards and guidelines are published by a variety of private and public organizations, including the:

Represents documentation of the patient's current and past health status?

Contains the physician's findings based on an examination of the patient?

What is the function of a consultation report?

What is the function of physician's orders?

An example of an advance directive?

In a medical history, which of the following is a detailed chronological description of the development of the patient's illness?

Represents the attending physician's assessment of the patient's current health status?

Patient history questionnaires are most often used in:

Which of the following is not an example of a long-term care setting?

An RAI/MDS and care plan are found in records of patients in:

In which setting may treatment records travel with the patient between treatment centers?

Documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record?

Which type of patient care record includes documentation of a family bereavement period?

When correcting erroneous information in a paper health record, which of the following is not appropriate?

Which accrediting organization has instituted unannounced surveys and requires submission of annual performance reviews?

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?

Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?

Which of the following is an advantage of paper-based records?

Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?

What is the general name for Medicare standards impacting healthcare organizations?