HIM 1000 CHAPTER 4 EXAM
QUESTIONS WITH CORRECT
ANSWERS
Which clinical data elements are not usually documented in the acute-care health
record? - Answer- Records of immunizations
Which is not a function of the discharge summary? - Answer- Providing information
about the patient's insurance coverage
Results of a urinalysis and all blood tests performed would be found in what part of a
healthcare record? - Answer- Laboratory findings
Which would not be considered clinical data? - Answer- Name of insurance company
Which of the federal laws resulted in the new privacy regulations for healthcare
organizations? - Answer- The Health Insurance Portability and Accountability Act
(HIPAA)
Which includes names of the surgeon and assistants, date, duration, and description of
the procedure and any specimens removed? - Answer- Operative report
Which materials are not documented in an emergency care record? - Answer- Patient's
complete medical history
Which types of facility are not generally governed by long-term care documentation
standards? - Answer- Assisted living facilities
Which of the specialized patient assessment tools must be used by Medicare-certified
home care providers? - Answer- Outcomes and Assessment Information Set (OASIS)
Which regulations are most commonly applied in end-stage renal disease treatment? -
Answer- Medicare Conditions for Coverage
Which statement is not true of the process that should be followed in making corrections
in paper-based health record entries? - Answer- The incorrect information should be
obliterated.
,Which types of healthcare facilities may seek accreditation from the Joint Commission?
- Answer- Acute care hospitals, Psychiatric hospitals, Home care providers, and
Ambulatory care organizations.
The federal Conditions of Participation apply to which type of healthcare organization? -
Answer- Organizations that treat Medicare or Medicaid patients
Which is not a traditional health record format? - Answer- Process-oriented health
record
Which health record format is most commonly used by healthcare settings as they
transition to electronic records? - Answer- Hybrid records
Which of the following is an example of administrative information? - Answer- The
patient's address
The health record contains the statement: The patient will be placed on IV antibiotics
and blood cultures will be taken. This statement is: - Answer- Plan
"Acute allergic reaction" would be documented in which part of a SOAP note? - Answer-
Assessment
What is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization? - Answer- Accreditation
Progress notes of physicians, nurses, therapists and other authorized individuals would
be found together in chronological sequence in a(an) _________ paper record. -
Answer- Integrated
Which part of a medical history documents the nature and duration of the symptoms
that caused a patient to seek medical attention as stated in that patient's own words? -
Answer- Chief complaint
Which of the following creates a chronological report of the patient's condition and
response to treatment during a hospital stay? - Answer- Progress notes
Which determines who can receive and transcribe verbal orders? - Answer- Medical
staff bylaws
In an integrated health record, documentation by health professionals is organized: -
Answer- Intermixed in date sequence
1. Which of the following is not an example of a long-term care setting?
A) Community mental health centers
B) Nursing homes
, C) Subacute care organizations
D) Assisted living facilities - Answer- A) Community mental health centers
Which 2 major types of data are contained in the health record? - Answer-
Administrative & clinical
Which of the following terms refers to state or county regulations that healthcare
facilities must meet to be permitted to provide care? - Answer- Licensure
Which of the following would NOT be found in a medical history? - Answer- Vital signs
An attending physician requests the advice of a second physician who then reviews the
health record & examines the patient. The second physician records impressions in
what type of report? - Answer- Consultation
Which specialized type of progress note provides healthcare professionals impressions
of patient problems with detailed treatment action steps? - Answer- Care plan
Written or spoken permission to proceed with care is calssified as? - Answer-
Expressed consent
Which of the following reports provides information on tissue remove during a
procedure? - Answer- Pathology report
Sleeping patterns, head & chest measurements, feeding & elimination status, weight,
and Apgar scores are recorded in which of following records? - Answer- newborn
Which of the following is not considered patient demographic information? - Answer-
Admitting diagnosis
Which of the following administrative documents names the patients choice of legal
representative for healthcare purposes? - Answer- Advance directive
Which type of health record contains information about care provided prior to arrival at a
healthcare setting & documentation of care provided to stabilize the patient? - Answer-
Emergency care
Patient history questionnaires, problem lists, diagnostic test results, & immunization
records are commonly found in which type of record? - Answer- Ambulatory care
The ambulatory surgery record contains information most similar to? - Answer- Hospital
operative records
Which standardized tool is used to assess Medicare-certified rehab facilities? - Answer-
Patietn assessment instrument (PAI)
QUESTIONS WITH CORRECT
ANSWERS
Which clinical data elements are not usually documented in the acute-care health
record? - Answer- Records of immunizations
Which is not a function of the discharge summary? - Answer- Providing information
about the patient's insurance coverage
Results of a urinalysis and all blood tests performed would be found in what part of a
healthcare record? - Answer- Laboratory findings
Which would not be considered clinical data? - Answer- Name of insurance company
Which of the federal laws resulted in the new privacy regulations for healthcare
organizations? - Answer- The Health Insurance Portability and Accountability Act
(HIPAA)
Which includes names of the surgeon and assistants, date, duration, and description of
the procedure and any specimens removed? - Answer- Operative report
Which materials are not documented in an emergency care record? - Answer- Patient's
complete medical history
Which types of facility are not generally governed by long-term care documentation
standards? - Answer- Assisted living facilities
Which of the specialized patient assessment tools must be used by Medicare-certified
home care providers? - Answer- Outcomes and Assessment Information Set (OASIS)
Which regulations are most commonly applied in end-stage renal disease treatment? -
Answer- Medicare Conditions for Coverage
Which statement is not true of the process that should be followed in making corrections
in paper-based health record entries? - Answer- The incorrect information should be
obliterated.
,Which types of healthcare facilities may seek accreditation from the Joint Commission?
- Answer- Acute care hospitals, Psychiatric hospitals, Home care providers, and
Ambulatory care organizations.
The federal Conditions of Participation apply to which type of healthcare organization? -
Answer- Organizations that treat Medicare or Medicaid patients
Which is not a traditional health record format? - Answer- Process-oriented health
record
Which health record format is most commonly used by healthcare settings as they
transition to electronic records? - Answer- Hybrid records
Which of the following is an example of administrative information? - Answer- The
patient's address
The health record contains the statement: The patient will be placed on IV antibiotics
and blood cultures will be taken. This statement is: - Answer- Plan
"Acute allergic reaction" would be documented in which part of a SOAP note? - Answer-
Assessment
What is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization? - Answer- Accreditation
Progress notes of physicians, nurses, therapists and other authorized individuals would
be found together in chronological sequence in a(an) _________ paper record. -
Answer- Integrated
Which part of a medical history documents the nature and duration of the symptoms
that caused a patient to seek medical attention as stated in that patient's own words? -
Answer- Chief complaint
Which of the following creates a chronological report of the patient's condition and
response to treatment during a hospital stay? - Answer- Progress notes
Which determines who can receive and transcribe verbal orders? - Answer- Medical
staff bylaws
In an integrated health record, documentation by health professionals is organized: -
Answer- Intermixed in date sequence
1. Which of the following is not an example of a long-term care setting?
A) Community mental health centers
B) Nursing homes
, C) Subacute care organizations
D) Assisted living facilities - Answer- A) Community mental health centers
Which 2 major types of data are contained in the health record? - Answer-
Administrative & clinical
Which of the following terms refers to state or county regulations that healthcare
facilities must meet to be permitted to provide care? - Answer- Licensure
Which of the following would NOT be found in a medical history? - Answer- Vital signs
An attending physician requests the advice of a second physician who then reviews the
health record & examines the patient. The second physician records impressions in
what type of report? - Answer- Consultation
Which specialized type of progress note provides healthcare professionals impressions
of patient problems with detailed treatment action steps? - Answer- Care plan
Written or spoken permission to proceed with care is calssified as? - Answer-
Expressed consent
Which of the following reports provides information on tissue remove during a
procedure? - Answer- Pathology report
Sleeping patterns, head & chest measurements, feeding & elimination status, weight,
and Apgar scores are recorded in which of following records? - Answer- newborn
Which of the following is not considered patient demographic information? - Answer-
Admitting diagnosis
Which of the following administrative documents names the patients choice of legal
representative for healthcare purposes? - Answer- Advance directive
Which type of health record contains information about care provided prior to arrival at a
healthcare setting & documentation of care provided to stabilize the patient? - Answer-
Emergency care
Patient history questionnaires, problem lists, diagnostic test results, & immunization
records are commonly found in which type of record? - Answer- Ambulatory care
The ambulatory surgery record contains information most similar to? - Answer- Hospital
operative records
Which standardized tool is used to assess Medicare-certified rehab facilities? - Answer-
Patietn assessment instrument (PAI)
