HIM 201: Chapter 4 Workbook Exam
Questions And Answers
/.a. I hereby acknowledge that Dr. Anyone has provided information about the
procedure described above, about my rights as a patient, and he or she answered all
questions to my satisfaction. Dr. Anyone has explained the risks and benefits of this
procedure to me. - Answer-✅Informed consent
/.b. Patient name, date of birth, patient gender, next of kin information - Answer-
✅Patient registration information or demographic information
/.c. You authorize your physician or other qualified medical providers to perform medical
treatment and services on your behalf. - Answer-✅General consent to treat
/.d. I understand that I have a right to restrict the manner in which my protected health
information is used and disclosed to carry out treatment, payment, or healthcare
operations. - Answer-✅Notice of privacy practices
/.e. A patient states that he has experienced difficulty swallowing for the last two weeks.
- Answer-✅Medical history
/.f. Neck: supple. Carotid pulses 2/7. Slight Jugular venous distention is noted. -
Answer-✅Physical examination
/.g. 6-2-2014 Admit via internal medicine. Urinalysis, Cardiac diet. - Answer-✅Physician
order(s) or admission order
/.h. I have recommended to Mr. Patient that we proceed with CT scan of head to rule
out bleed. Thank you for allowing me to participate in Mr. Patient's care today. - Answer-
✅Consultation
/.i. Time: 0120 Temperature 36, Pulse 144, Respiration 46 - Answer-✅Vital signs
/.j. PT: 17.6 H, INR: 1.9, PTT: 32.0 H=High - Answer-✅Laboratory report
/.k. Exam Date: 12/8/15 Check in# 15 Exam# 42589 PA and Lateral Chest: 12/8/15
Findings: The lungs are clear - Answer-✅Diagnostic report or imaging report
/.l. Date: 6/8/15 Surgeon: Dr. Anyone Assistant: None Anesthetic: Spinal Complications:
None Operation: Right Carotid Endarterectomy - Answer-✅Operative report
, /.m. Disposition: No lifting greater than 15 lbs. No driving for 6 weeks. Final Diagnosis:
Coronary Artery Disease - Answer-✅Discharge summary
/.n. Activity: Up in chair 0700 6/19/15 Hygiene: Shower Nutrition: 2/3 eaten IV Pump:
D/C - Answer-✅Progress note
/.o. 38 weeks gestation, Apgar's 8/9, 6# 9.8 oz. good cry, to room with mom - Answer-
✅Newborn record
/.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 health record format is most commonly used by healthcare settings as they
transition to electronic records? - Answer-✅Hybrid records
/.What is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization? - Answer-✅Accreditation
/.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 is an example of administrative information? - Answer-
✅Patient's address
/.The federal Conditions of Participation apply to which type of healthcare organization?
- Answer-✅Organizations that treat Medicare or Medicaid patients
/.Which of the following materials is documented in an emergency care record? -
Answer-✅Time and means of the patient's arriva
/.Which of the following statements is true of the process that should be followed in
making corrections in paper-based health record entries? - Answer-✅The reason for the
change should be noted
/.Which of the following types of facilities is generally governed by long-term care
documentation standards? - Answer-✅Subacute care
/.Which of the following includes names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed? - Answer-✅Operative
report
/.Which of the following is a function of the discharge summary? - Answer-✅Ensuring
the other healthcare providers know what to do next while the patient is hospitalized
Questions And Answers
/.a. I hereby acknowledge that Dr. Anyone has provided information about the
procedure described above, about my rights as a patient, and he or she answered all
questions to my satisfaction. Dr. Anyone has explained the risks and benefits of this
procedure to me. - Answer-✅Informed consent
/.b. Patient name, date of birth, patient gender, next of kin information - Answer-
✅Patient registration information or demographic information
/.c. You authorize your physician or other qualified medical providers to perform medical
treatment and services on your behalf. - Answer-✅General consent to treat
/.d. I understand that I have a right to restrict the manner in which my protected health
information is used and disclosed to carry out treatment, payment, or healthcare
operations. - Answer-✅Notice of privacy practices
/.e. A patient states that he has experienced difficulty swallowing for the last two weeks.
- Answer-✅Medical history
/.f. Neck: supple. Carotid pulses 2/7. Slight Jugular venous distention is noted. -
Answer-✅Physical examination
/.g. 6-2-2014 Admit via internal medicine. Urinalysis, Cardiac diet. - Answer-✅Physician
order(s) or admission order
/.h. I have recommended to Mr. Patient that we proceed with CT scan of head to rule
out bleed. Thank you for allowing me to participate in Mr. Patient's care today. - Answer-
✅Consultation
/.i. Time: 0120 Temperature 36, Pulse 144, Respiration 46 - Answer-✅Vital signs
/.j. PT: 17.6 H, INR: 1.9, PTT: 32.0 H=High - Answer-✅Laboratory report
/.k. Exam Date: 12/8/15 Check in# 15 Exam# 42589 PA and Lateral Chest: 12/8/15
Findings: The lungs are clear - Answer-✅Diagnostic report or imaging report
/.l. Date: 6/8/15 Surgeon: Dr. Anyone Assistant: None Anesthetic: Spinal Complications:
None Operation: Right Carotid Endarterectomy - Answer-✅Operative report
, /.m. Disposition: No lifting greater than 15 lbs. No driving for 6 weeks. Final Diagnosis:
Coronary Artery Disease - Answer-✅Discharge summary
/.n. Activity: Up in chair 0700 6/19/15 Hygiene: Shower Nutrition: 2/3 eaten IV Pump:
D/C - Answer-✅Progress note
/.o. 38 weeks gestation, Apgar's 8/9, 6# 9.8 oz. good cry, to room with mom - Answer-
✅Newborn record
/.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 health record format is most commonly used by healthcare settings as they
transition to electronic records? - Answer-✅Hybrid records
/.What is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization? - Answer-✅Accreditation
/.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 is an example of administrative information? - Answer-
✅Patient's address
/.The federal Conditions of Participation apply to which type of healthcare organization?
- Answer-✅Organizations that treat Medicare or Medicaid patients
/.Which of the following materials is documented in an emergency care record? -
Answer-✅Time and means of the patient's arriva
/.Which of the following statements is true of the process that should be followed in
making corrections in paper-based health record entries? - Answer-✅The reason for the
change should be noted
/.Which of the following types of facilities is generally governed by long-term care
documentation standards? - Answer-✅Subacute care
/.Which of the following includes names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed? - Answer-✅Operative
report
/.Which of the following is a function of the discharge summary? - Answer-✅Ensuring
the other healthcare providers know what to do next while the patient is hospitalized
