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HIT 101 Final Exam

Final Exam Review

Question	Answer
Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie’s attending physician. Who must sign the history and physical?	Dr. Johns must sign the report first and then Dr. Blake must countersign.
Which statement regarding the patient record is true?	All entries must be legible and complete.
Every report and every page/screen in a manual or computerized patient record should minimally include	patient name and medical record number.
The process of advising a patient about treatment options is documented on a form known as	informed consent.
A hospital that provides emergency care, performs surgery, and admits patients for a range of problems is a ____ hospital.	general
What was the intention of managed care?	To manage cost, quality, and access to care
Which of the following statements most accurately describes the Medicaid program?	care for the poor
A hospital that provides health care services to patients who have serious, sudden, or acute illnesses or injuries and/or need surgeries is a(n) ____ facility.	acute care
The type of care that provides comprehensive medical and supportive social, emotional, and spiritual care to terminally ill patients and their families is known as _____ care.	hospice
The JCAHO requires patient records to be completed ____ days after a patient is discharged.	30
Dr. Jones records the following information in the ____ section of a patient’s SOAP note: BP is 120/74. Temperature is 100. Upon examination, lungs are clear but patient has nasal congestion.	objective
The agency that cares most about a facility’s incomplete medical record is:	JCAHO
Which of the following laws resulted in the new privacy regulations for healthcare organizations?	The Health Insurance Portability and Accountability Act
Which of the following is an example of an advance directive affected under the Patient Self Determination Act?	A living will
Which of the following could be considered a candidate for hospice care	was diagnosed with Alzheimer’s disease.
How do accreditation organizations use the health record?	to determine whether standards of care are being met
To meet the Medicare COP, an acute facility must be accredited by	JCAHO
Who has ulimate responsibility for guaranteeing quality care?	Governing Board
The Verteran’s Administration Hospital is an example of what type of facility	government owned, federal
When a physician applies for medical staff privileges at an acute care facility, final approval (or denial) of the application is the responsibility of the	Governing Board
The insurance program implemented to care for the elderly is	Medicare
What documents stipulate the principles and policies with which each medical staff member agrees to comply and are accepted by the courts as a basis for legal decisions	Medical Staff Bylaws, Rules and Regulations
JCAHO was formed to take over the accreditation process from	ACS
JCAHO requires a physician be re-credentialed by a healthcare organization:	every two years
Which joint state and federal program(s) assist with medical costs for those with low incomes and limited resources?	Medicaid
The Hill-Burton Act was passed to provide federal grants to modernize hopstials during the Great Depression and WWII. In return for federal funds, facilities agreed to	provide free or reduced charge medical services to individuals who were unable to pay
Dr. Smith asked Dr. Jones to come to the hospital to evaluate one of his patients with a rare blood disorder. Dr. Jones has privileges that let him see other physician’s patients but not to admit his own patients. Dr. Jones has which type of privileges	consulting
Most hospitals in the US are ____ and are operated by religious or other charitable groups.	voluntary
Which medical staff membership category includes physicians who deliver most of the hospital’s inpatient medical services?	active
Which is an example of clinical data?	diagnosis
An admissions clerk enters “right lower abdominal pain” as the admission diagnosis on the face sheet. This information is known as	clinical data.
The JCAHO requires that the history and physical examination be documented in the patient record within ____ of inpatient admission.	24 hours
Pre- and postanesthesia evaluations would be found in a(n) ____ record.	surgical care
Dr. Green discovers that she has recorded the progress note of John Ray on Mary Smith’s chart. In order to make a proper correction, the doctor should	draw a single line through the incorrect note, write the word error, date and initial the change
A History and Physical can be completed prior to admission for an elective surgical procedure	True
Resident identification, demographics, and physician admitting diagnosis are located on what form?	admission/discharge sheet
The record format which organizes the record in date order within sections according to patient care departments, such as physican orders, nurses notes, etc is know as	source oriented
Which of the following would be responsible for obtaining special consents for surgical procedures?	Attending physician
Erica is responsible for releasing information from patient’s records after they have been discharged. The report in the record (if properly documented) that gives all information to fulfill requests from other doctor’s providing care is	discharge summary
An essential item to be captured on the physical exam is the	objective survey of body systems
An essential item to be captured on the physical exam is the	objective survey of body systems
The type of review that is generally done while a patient is in the facility is known as	concurrent review
Medical reocrd with specific defiencies that have not been completed within the acceptable time limit is called	delinquent records
Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient’s health record?	rubber stamp signature of the radiologist by the department secretary
The purpose of quantitative analysis of the medical record is	to ensure a complete and adequate medical record
_____________________ was passed by the U.S. Congress and signed into law in 1996. Its goal was to make health insurance portable from one job to another and to secure the privacy of medical records.	HIPAA
________________ is the use of computers and software to enter prescriptions and send them to pharmacies electronically.	e-prescribing
Which of the following is not an example of discreet data	dictation
The type of RHIO where the facility sends information to a centralized location so it is available for access is the	Consolidated model
Which of the following best describes the mission of the AHIMA?	Community of professionals providing support to members and strengthening the industry and profession
How do patient care managers and support staff use the data documented in the health record?	to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided
Which of the following statements does not pertain to paper-based health records?	They have a built-in access control mechanism.
Use of the health record by a clinician to facilitate quality patient care is considered	a primary purpose of the health record
Facilities that provide patient care for a period of time longer than 30 days are generally known as	long term care facilities
The primary purpose of keeping records is	as a means of communication between health care professionals contributing to the patient’s care
To determine how many doses of a particular medication a patient received, you would look at the	MAR
Microscopic description of any specimen removed during a surgical procedure would be described on the	pathology report
The graphing report would not typically include	date of last flu shot
Which component of a registry identifies the number of cases reviewed in a given year?	accession register
The master patient index should be retained	permanently
Arrange the following numbers in middle digit order: 01-30-49, 01-31-40, 02-30-49, 02-36-40, 20-39-50, 03-40-50.	01-30-49, 02-30-49, 01-31-40, 02-36-40, 20-39-50, 03-40-50
A disadvantage of the serial numbering system is that	multiple locations must be accessed to retrieve patient records.
Sally Smith is admitted to Sunny Valley Hospital wearing a diamond ring. This should be documented on the	patient property form.
Dr. Jones completes an admission history and physical on Bob Lot, who states, “When I walk up stairs I have difficulty breathing.” This statement is known as the patient’s	chief complaint.
An APGAR score is documented in the	newborn record.
Facilities that provide patient care for a period of time longer than 30 days are generally known as	long term care facilities
The primary purpose of keeping records is	as a means of communication between health care professionals contributing to the patient’s care
Microscopic description of any specimen removed during a surgical procedure would be described on the	pathology report
Which of the following is true with regard to terminal digit filing?	It provides a high degree of record security.
An essential item to be captured on the physical exam is the	objective survey of body systems
Abbreviations and symbols are to be used in patient records when	they are part of a published facility list that has been approved by the medical staff
Medical reocrd with specific defiencies that have not been completed within the acceptable time limit is called	delinquent records
An admissions clerk enters “right lower abdominal pain” as the admission diagnosis on the face sheet. This information is known as	clinical data.
Which is an example of clinical data?	diagnosis
Most hospitals in the US are ____ and are operated by religious or other charitable groups.	voluntary
Pre- and postanesthesia evaluations would be found in a(n) ____ record.	surgical care
Which joint state and federal program(s) assist with medical costs for those with low incomes and limited resources?	Medicaid
What documents stipulate the principles and policies with which each medical staff member agrees to comply and are accepted by the courts as a basis for legal decisions	Medical Staff Bylaws, Rules and Regulations
The Verteran’s Administration Hospital is an example of what type of facility	government owned, federal
Who has ulimate responsibility for guaranteeing quality care?	Governing Board
JCAHO was formed to take over the accreditation process from	ACS
The Medicare program is governed under which title of the Social Security Act?	Title XVIII
To meet the Medicare COP, an acute facility must be accredited by	JCAHO
How do accreditation organizations use the health record?	to determine whether standards of care are being met
The first president of the association currently known as American Health Information Management Association was	Grace Whiting Myers
Dr. Jones records the following information in the ____ section of a patient’s SOAP note: BP is 120/74. Temperature is 100. Upon examination, lungs are clear but patient has nasal congestion.	objective
Nurse Jones takes a telephone order from Dr. Blake. Determine which of the following should occur.	Dr. Blake needs to sign the order within the time period specified by the facility’s medical staff bylaws.
What was the intention of managed care?	To manage cost, quality, and access to care
The original copy of the medical record in a hospital is considered the physical property of	the health care facility
A hospital that provides health care services to patients who have serious, sudden, or acute illnesses or injuries and/or need surgeries is a(n) ____ facility.	acute care
A hospital that provides emergency care, performs surgery, and admits patients for a range of problems is a ____ hospital.	general
Every report and every page/screen in a manual or computerized patient record should minimally include	patient name and medical record number.
Which of the following could be considered a candidate for hospice care	was diagnosed with Alzheimer’s disease.

Created by: mkaila

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