Help
Options
Question
A health record is considered
click to flip
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't know
Question
A medical report is a
Remaining cards (174)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Stack #615300
| Question | Answer |
|---|---|
| A health record is considered | C. Both A and B |
| A medical report is a | D. Both A and C |
| The key to substantiating procedure and diagnostic code selections for proper reimbursement is | B. supporting documentation in the health record |
| The chronologic recording of pertinent facts and observations about the patient's health is known as | C. Documentation |
| Reasons for documentation are | C. Both A and B |
| The SOAP in patient medical record charting may be defined as | B. Subjective, Objective,Assessment, Plan |
| When a patient fails to return for needed treatment, documentation should be made | D. All of the above |
| How should an entry in a patient's medical record be corrected? | A. Cross out the incorrect entry, substitute the correct information, date and initial the entry |
| A concise statement describing the symptom, problem, condition, diagnosis, physician-recommeneded return, or other factor that is the reason for the encounter is abbreviated as? | A. CC |
| Levels of evaluation and management services are based on types of physical examination that may be | C. Problem focused |
| An expanded problem-focused examination is a/an | C. limited examination of the affected body area |
| The official American Hospital Association policy states that abbreviations should be totally eliminated from the more vital sections of the record, such as the | D. All of the above |
| A diseased condition or state is known as | B. Morbidity |
| What does comorbidity mean? | C. Underlying disease or other conditions present at the time of visit. |
| A new patient is one who? | C. Has not received any professional services from the physician within the past 3 yrs |
| An established patient is one who? | B. Has previously recieved professional services from a physician or another physcian of the same specialty within the last 3 years |
| In dealing with managed care plans, a referral is? | D. Both B and C |
| Your physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered? | B. Critical Care |
| When a discussion takes place with a patient concerning the risks and benefits of treatment options it is considered? | C. counseling |
| Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the? | C. right lower quadrant |
| Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as? | C. Intermediate |
| The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading | A. simple |
| A review of patient records done before billing is submitted is called? | B. prospective |
| Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime. | A. exclusion from program participation is mandatory |
| Which of the following cases should not use fax transmission? | D. All of the above |
| Who may accept a subpoena? | C. Both A and B |
| Preservation of health records is governed by? | Both B and C |
| Records that must be retained indefinitely include | C. patient's medical records, x-ray films, and inactive patient's medical records |
| Social changes as well as medical specialization have altered what needs to be done with patient's medical records. | A. True |
| The acronym HIPAA stands for? | D. health Insurance Portability and Accountability Act |
| In 2000 congress appropiated 50 million to ---- to support a variety of efforts targeted at reducing medical errors | A. AHRQ |
| As many as ___ people die in hospitals each year as a result of medical errors that could have been prevented | D. 98,000 |
| CPOE is an acronym for | B. computerized physician Order entry |
| SOAP is an acronym for | D. subjective, objective, assessment, plan |
| The concept of computerizing a patient's medical record has been around for? | A. 30 years |
| A study by the Center for Information Technology Leadership found more than 130,000 life threatening situations caused by adverse drug reactions | A. True |
| The IOM put forth a set of___ core functions that an EHR should be capable of performing | A. 8 |
| A laboratory requisition records information about the patient, the clinician, and the___ | B. test to be performed |
| IOM stands for? | A. Institute of Medicine of the National Academies |
| DAW is a pharmacy acronym for? | D. dispense as written |
| The simplest example of health maintenance is a card or letter remindind the patient that it is time for a check up | A. True |
| EHR is an acronym for electronic Health record | A. True |
| ___are used to look up drugs by names or therapeutic classes | A. Drug formularies |
| The goal of the EHR is not to eliminate paper charts, but rather to eliminate paper charts being the only form of chart used | A. True |
| A non-profit org, that developed and maintains the leading messaging standard used to exchange clinical and administrative data between different health care computer systems is | D. health level seven |
| Which of the following is not one of the core functions of the EHR set by the IOM? | C. paper support |
| The father of the problem-oriented chart was? | C. Dr. Lawrence Weed |
| Drawbacks to paper records includ the fact that they are? | D. B and C |
| AHRQ is an acronym for | A. Agency for healthcare research and quality |
| Which of the following is not one of the three key criteria identified by the computer-based patient record institute? | C. institute universal abbreviations |
| The new position established in an Executive Order signed by President Bush in 2004 was____ | A. National Coordinator for Health Information Technology |
| The IOM study focused on medical erors occurring is hospitals, but other studies showed an even larger number of medical errors occurring in___ | C. outpatient facilities |
| AHRQ is an acronym for | A. Agency for healthcare Research and quality |
| CPRI stands for___ | A. computer-based Patient Record Institute |
| DUR is an acronym for? | C. Drug utilization review |
| HIPAA was passed by congress in___? | A. 1996 |
| A new staff position that some clinics may choose to utilize with the use of EHR is? | C. Medical Scribe |
| A(n)___is a term used in an EHR for a message or reminder that is automatically generated from the data | A. alert |
| Medical vocabulary used in an EHR should be codified because there are so many | B. words that mean the same thing |
| MRI is an acronym for medical record initiative | B False |
| HIT is an acronym for? | B. Health information Technology |
| the concept of computerizing a patient's medical record has been around for about 50 yrs | B. False |
| EHR is an acronym for ? | B. Electronic health Record |
| NOC is an acronym for? | D. Nursing Outcomes Classification |
| The newest revision of the ICD-9 is the ICD-10 and it was released by the WHO in 1992 | A. True |
| Which volume of the ICD-9 is used to bill for hospital procedures? | C. 3 |
| What way of storing information is the most common way to store in the EHR system and is fast, efficient, and uses very little storage space? | C. fielded data |
| Current Procedural Terminology was created in? | A. 1968 |
| EHR users tend to locate findings by the ___, not the code | C. description |
| PCDS has more components than the Omaha System? | A. True |
| The ICD-9CM currently is published in___volumes | C.3 |
| What is the code set designed for documenting nursing interventions in any clinical setting? | D. Nursing Interventions Classification |
| NIC stands for nursing interventions classification and is a code set designed for documenting nursing interventions in? | D. any clinical setting |
| ___provides a universal coding system for mapping laboratory tests and results to a common terminology in the EHR | A. LOINC |
| Which of the following is not one of the ways that patient records can be stored? | A. protected data |
| NOC can be used to measure? | D. All of the above |
| The FDA began maintaining a list of all drugs prepared or sold by registered drug companies in___ | A. 1973 |
| CMS is an acronym for? | D. centers for medicare and Medicaid Services |
| Each drug product listed by the FDA is assigned a unique___digit number | C. 10 |
| Which of the following is not a domain in the system of nursing interventions classifications? | A. education |
| PCDS stands for Patient Care Data Set and was developed by physicians at Harvard | B. False |
| Health and human services and the dept of defense and vetrens affairs agreed to endorse a set of standards in? | d. 2004 |
| The largest number of LOINC codes are in the ___section | a. LABORATORY |
| To bill for a patient who is not sick, the ICD-9 code would start with the letter? | c. v |
| NANDA states that "A clinical judgement about individual, family, or community response to actual or potential health problems/life processes is a(n) | A. nursing diagnosis |
| When a code is stored in the medical record in addition to thee text description, the record is considered codified | A. True |
| HCPCS codes were created for billing | B. supplies, injectable medications, and blood products |
| CPT codes were created by the American Medical Association | A. True |
| How many standards are recognized by the north american nursing diagnosis association for use in the assessment, diagnosis, interventions, and outcomes of nursing care? | C. 13 |
| Nomenclature is from a latin term and means? | C. a list of names |
| ICD-10PCS has been proposed to replace | B. ICD-9 volume 3 |
| A code set designed specifically to record medical observations is often referred to as a clinical | D. nomenclature |
| ___ in the EHR are automatic messages to the clinician or other staff person | D. Alerts |
| International classification of disease codes are maintained by the | C. World Health Organization |
| The Omaha system is made up of ___components | C. 3 |
| FDA is an acronym for | C. Food and Drug Administration |
| Which of the following is not a category of medcin? | A. prognosis |
| CPT-4 codes were adopted by the government in? | C. 1983 |
| Lab tests are a good example of codified data | A. true |
| What are the three portions of LOINC? | A. laboratory, clinical, and HIPAA |
| EHR nomenclatures need to have alot more codes to describe the details of the exam, for this reason they are said to be | B. granular |
| The standard identifier for human drugs is? | C. NDC |
| There are___different code sets offically recognized by the american nurse association | D. 13 |
| A nomenclature is a system of names used in a field of science, typically created by a recongnized group or authority | A. True |
| SNOMED is an acronym for Selected Nomenclature of medicine | B. false |
| In medicine there is only one way to describe a symptom, condition, or observation | B. False |
| Which is not one of the components of the Omaha system? | B. problem updating area |
| The omaha system is a standardized terminology recognized by the american nurses association | A. true |
| Health and human services and the dept of defense and veterans affairs agreed to endorse a set of ___ standards | D. 20 |
| In the term rheumatoid, the root rheumat means? | A. discharge |
| In the term phosphorus, the root phos means? | A. light |
| A sutural or__ bone is found between the flat bones of the skull? | A. wormian |
| The process of bending a limb is called? | A. flexion |
| In the term arthroscope, the suffix-scope means? | D. instrument |
| A condition that is characterized by the progressive loss of bone density and thinning of bone tissue is called | B. osteoporosis |
| A lateral curvature of the spine is known as? | C. scoliosis |
| The prefix dis- means | C. apart |
| In the term cartilage, the root cartil means | C. gristle |
| In the term chondrocostal, the root cost means | B. rib |
| In the term meniscus, the root menisc means | D. cresent |
| In the term cartilage, the suffi-age means? | A. related to |
| All of the following are classified as long bones except? | B. vertebrae |
| All of the following are functions of the skeletal system except? | A. acid-base balance |
| The membrane that forms the covering of bones except at their articular surfaces is called? | A. periosteum |
| A disease that involves inflammation of the joints is called? | A. arthritis |
| What structure is narrow passageway about as big around as ones thumb and located on the palm side of the wrist? | C. Carpal tunnel |
| The medical word for pertaining to the lower jawbone? | C. mandibular |
| The medical word for pertaining to the elbow is? | D. olecranal |
| The medical term for the big toe is | D. Hallux |
| A___fracture occurs at the ankle and affects both bones of the lower leg | A. Potts |
| Inflammation of the bone and joint is | B. osteoarthritis |
| The medical term for the heel bone is | A. calcaneus |
| the medical term for a fingerprint is? | B. dactylogram |
| Which bone is not located in the upper extremity? | D. femur |
| The medical term for knock-knee | D. gene valgum |
| Abnormal anterior curvature of the spine is called | D. lordosis |
| The ____ is the shaft of long bone | C. diaphysis |
| An opening in the bone for blood vessels, ligaments, and nerves is called | C. forearm |
| Bending a limb is called? | D. flexion |
| Lying with the face upward is called? | D. supination |
| An open fracture is called | B. compound |
| A condition of stiffening of ajoint is? | A. ankylosis |
| The bones of the wrist are called? | C. carpals |
| A diagnostic examination of a joint whee air and then a radiopaque contrast medium are injected into the joint space | C. arthrography |
| The process of recording heat patterns of the body's surface is called? | C. thermography |
| Which substance is increased i gout, arthritis, myeloma,rheumatism | C. uric acid |
| the ___ level in the blood may be increase in osteomalacia and fracture healing | C. alkaline phoshatase |
| which substance/s is/are present in a variety of immunologic diseases? | A. uric acid |
| Swayback is another word for? | D. lordosis |
| The solid matter in bone is known as | C. osseous tissue |
| All of the following are functions of bone except | D. hormone production |
| An articulation refers to a(n)? | D. joint |
| A rounded process that enters into the formation of a joint is | B. condyle |
| Synarthrosis is a type of joint | C. does not permit movement |
| Example of an amphiarthrosis joint is the | B. vertebrae |
| The process of moving a baody part away from the middle is | B. abduction |
| The suffix in flexion means | C. process |
| The cervical curve consists of ___ vertebrae? | B) 7 |
| the center for longitudinal bone growth in childern is | D. Epiphyseal plate |
| The daily recommeneded amount of calcium for age 12 is | A. 1300 mg |
| Women build bone until about age? | D. 35 |
| A term to describe loss of bone mass is | B.osteoporosis |
| The combining form in achondroplasis means? | C. cartliage |
| The term ankylosis means? | A. condition of stiffening of a joint |
| The combining form in calcaneal means? | D. heel bone |
| A term that means humpback is? | C. kyphosis |
| The suffix in lumbodyynia means? | D. pain |
| The term myelopoiesis means? | B. formation of bone marrow |
| The term used to describe softening of the bone is? | B. osteomalacia |
| The combining form in rachigraph means? | C. Spine |
| Drugs that can be used for skeletal system diseases and disorders include | D. all of the above |
| An abnormal lateral curvature of the spine is? | D. scoliosis |
| A___fracture usuallyoccurs in childern? | B. greenstick |
| Which fracture occurs at ankle and affects both bones of the lower leg? | B. Pott's |
| The surgical puncture of a joint for removal of fluid is? | C. arthrocentesis |
Created by:
1387441007