WGU BDV1 Mod 4 Health Data Management across the continuum (AHIMA C2V3)
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| A health record available electronically allowing communication across providers and permitting real-time decision making. | show 🗑
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| A health record that uses components of both paper and electronic systems. | show 🗑
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| show | Clinical and Adminstrative
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| Which of the following is a health record not used for? (Patient Care, Provider Commication, Evaluating Care, Disease Management, Substantiating Billing Claims, Legal Interests) | show 🗑
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| show | Government Reimbursement Programs
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| Documents the patient's current complaints and symptoms and lists past medical, personal, and family history. | show 🗑
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| show | Physical Exam Report
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| show | Progress Note
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| This is assumed when a patient voluntarily submits to treatment. | show 🗑
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| This is in effect when consent is given either spoken or written. | show 🗑
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| This document notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, duration of administration, and patient's vital signs while under anesthesia. | show 🗑
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| This document describes the surgical procedures performed on the patient and is dictated ot written by the surgeon following the procedure. | show 🗑
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| This document includes the postanesthesia note, nurses's note regarding patient's condition, surgical site, vital signs, fluids given, and monitoring. | show 🗑
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| This document provides a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time of discharge from the hospital. | show 🗑
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| What documents the continuity of care, supports activities for medical staff review, and concise information used to answer requests for information by authorized indivudlas or entities. | show 🗑
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| show | Consent to treatment
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| show | Consent to treatment
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| The privacy rule requires providers to secure the patient's written acknowledgement that he or she has received this document. | show 🗑
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| show | Authorization to disclose information
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| This is a legal document that contains the patient's choice for legal representative for healthcare purposes. | show 🗑
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| These physician orders should be consistent with the patient's advanced directives. | show 🗑
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| This regulation includes acknowledgment forms used to document the patient received information about their rights while a patient. | show 🗑
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| This is another name for the Patient's Bill of Rights. | show 🗑
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| show | Licensure
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| show | Care Plan
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| An APGAR Score is likely found in what type of chart? | show 🗑
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| This organization issues specific health informaiton standards for acute care hopitals. | show 🗑
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| This organization issues specific health informaiton standards for rehab hospitals | show 🗑
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| Ambulatory care records typically includes this document to facilitate ongoing patient care management, but it isn;t typically included on acute care records. | show 🗑
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| show | Problem List
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| Some physican practices use this to collect past medical history informaiton from the patient. | show 🗑
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| show | Accreditation Association for Ambulatory Health Care (AAAHC)
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| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | show 🗑
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| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | show 🗑
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| show | National Committee for Quality Assurance (NCQA)
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| show | Obstetric/Gynecologic
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| show | Resident assessment instrument (RAI)
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| The RAI includes MDS, triggers, utilization guidelines, and _______ ________ ________. | show 🗑
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| show | Minimum Data Set (MDS)
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| Medicare certified home health agencies use this standardized patient assessment insrutment for the plan of care and reimbursement. | show 🗑
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| Care provided to terminally ill patients and supportive services to patients and families. | show 🗑
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| This document is completed shortly after admisison and upon discharge to an inpatient rehab facility. | show 🗑
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| Medicare requires this for various settings of care for End-Stage Renal Disease. | show 🗑
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| An electronic, universally available, lifelong resource of health information needed by individuals to make health decisions. | show 🗑
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| Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentaiton of care provided to stabilize the patient? | show 🗑
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| Patient history quesionnaires, problem lists, diagnostic test results, and immunization records are found in which type od record? | show 🗑
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| Ambulatory surgery record contains information most similar to ___________. | show 🗑
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| Which standardized tool is used to assess Medicare-certified rehab facilities? | show 🗑
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| show | Ambulatory care
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| show | Home Health and End-Stage Renal Disease
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| Paper records may require thenning in which two settings? | show 🗑
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| In 2004 JCAHO implemented a new survey process called Shared Visions-New Pathways to bring what changes? | show 🗑
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| Accreditation manuals often include documentation standards in a section called what? | show 🗑
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| The American Osteopathic Association (AOA) originally began for what purpose? | show 🗑
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| Which of these services are not accredited by CARF? (Medical Rehab, End-Stage Dialysis, Assisted Living, Behavorial Health, Adult day care, employment and community centers) | show 🗑
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| show | National Committee for Quality Assurance (NCQA)
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| Organizations receiving funding for services to Medicare patients must comply with what? | show 🗑
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| show | 30, 24
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| What is the correct section of the medical record to contain Vital Signs? | show 🗑
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| show | Social history of a Medical History
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| What is the correct section of the medical record to contain the referral of the patient to a physical therapist for treatment? | show 🗑
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| What is the correct section of the medical record to contain the Systematic Inventory? | show 🗑
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| show | Discharge Summary
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| show | Joint Commission
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| What organization is the source of documentation standards or guidelines for Osteopathic residency programs? | show 🗑
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| What organization is the source of documentation standards or guidelines for Ambulatory care? | show 🗑
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| What organization is the source of documentation standards or guidelines for Rehabilitation hospital? | show 🗑
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| What organization is the source of documentation standards or guidelines for Managed care assessment of in-plan providers? | show 🗑
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| Which of the medical record form/report summarizes the patient's medical and surgical conditions? | show 🗑
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| Which of the medical record form/report is a component of the medical history? | show 🗑
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| show | Operative Report
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| show | Consultation Report
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| show | Progress Note
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| show | Subjective: Patient's complaints and comments
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| show | Objective: Physical findings and laboratory data
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| show | Assessment: Diagnosis and impression
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| In a SOAP Note, what is the "P" represent? | show 🗑
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