HIM 103 CHAPTER 4 EXAM QUESTIONS
WITH CORRECT ANSWERS
What do you call an accident or medical error that results in personal injury or loss of
property? - Answer- Potentially Compensable Event (PCE)
Reviewing the medical record during inpatient hospitalization for quality documentation
is called - Answer- Concurrent Analysis
The process of authenticating a dictated report prior to its transcription is called -
Answer- Auto-Authentication
The organization of reports in the inpatient and discharged record is determined by the -
Answer- Health Care Facility or Provider
Which of the following addresses the admissibility of copies of records in court? -
Answer- Uniform Business Records as Evidence Act
When responsible providers authenticate entries that they did not originally document,
they do so with a(n) _______. - Answer- countersignature
Insurance number and guarantor are considered a _______ type of patient data. -
Answer- financial
The readability of a medical record entry is known as _______. - Answer- legibility
A minimum set of data to be collected on every patient, such as chief complaint;
diagnoses; social data; history; review of systems; physical examination; and baseline
laboratory data is called a(n) _______. - Answer- database
The S in a SOAP format progress note stands for _______. - Answer- subjective
Incomplete records are considered delinquent after how many days? - Answer- 30
A technical control created by an electronic health record (EHR) system that lists all
transactions and activities on the system is called _______. - Answer- audit trail
What type of manager plays an important role in educating physicians about proper
documentation practices? - Answer- Health information management
WITH CORRECT ANSWERS
What do you call an accident or medical error that results in personal injury or loss of
property? - Answer- Potentially Compensable Event (PCE)
Reviewing the medical record during inpatient hospitalization for quality documentation
is called - Answer- Concurrent Analysis
The process of authenticating a dictated report prior to its transcription is called -
Answer- Auto-Authentication
The organization of reports in the inpatient and discharged record is determined by the -
Answer- Health Care Facility or Provider
Which of the following addresses the admissibility of copies of records in court? -
Answer- Uniform Business Records as Evidence Act
When responsible providers authenticate entries that they did not originally document,
they do so with a(n) _______. - Answer- countersignature
Insurance number and guarantor are considered a _______ type of patient data. -
Answer- financial
The readability of a medical record entry is known as _______. - Answer- legibility
A minimum set of data to be collected on every patient, such as chief complaint;
diagnoses; social data; history; review of systems; physical examination; and baseline
laboratory data is called a(n) _______. - Answer- database
The S in a SOAP format progress note stands for _______. - Answer- subjective
Incomplete records are considered delinquent after how many days? - Answer- 30
A technical control created by an electronic health record (EHR) system that lists all
transactions and activities on the system is called _______. - Answer- audit trail
What type of manager plays an important role in educating physicians about proper
documentation practices? - Answer- Health information management
