CRIS TEST COMPREHENSIVE QUESTIONS WITH
MULTIPLE CHOICES |VERIFIED & REVISED
ANSWERS (NEW) 2026
Save
Terms in this set (56)
Purposes of medical record 1. To provide a communication tool between all
healthcare providers. A physician, nurse, and any
healthcare professional that treats the patient will
complete documentation within the medical
records
2. To provide documentation regarding diagnosis,
treatment, and care of the patient while to find a
receiving services from a healthcare facility.
3. To provide information needed for medical
billing of services rendered to the patient and
hospital financial management.
4. To provide a medium for analysis, study, and
evaluation of the quality of care given to a
patient.
5. To assist in protecting the legal rights of the
patients, the healthcare facility, and other
healthcare providers.
A master patient index (MPI) Tool gathered to obtain the complete medical
record. (Is electronic medical database that holds
information on every patient registered at a
healthcare organization.)
, Discharge summary Summary of treatment the patient received.
Includes the diagnosis of their ailment. This is
usually a transcribed report.
history and physical Reflects the history of the patients disease or
injury, as well as the history of treatment. Usually
transcribed, but may be hand written at the
beginning of the progress notes.
Electrocardiogram (EKG or ECG) & These are specialized tests for the heart (EKG)
electroencephalogram (eeg) and the brain (EEG) that produce strips of
findings that may be mounted on individual
pages.
Pulmonary function test (PFT) A test designed to measure how well the lungs
are working usually found in the respiratory
section.
Operative report This is a summary report of the operation
including a description of what was done and the
findings.
Pathology report An analysis of anything removed from the patient
during the operation (i.e. To check for cancer)
Continuity of care document (CCD) The CCD is generated from an electronic health
record (EHR). It is a summary data set with
demographic & clinical information about a
patients healthcare covering one of more
encounters.
Who owns the medical record? It is the property of the facility in which it was
created.
Which law is stronger if in conflict? Whichever is stricter than the 2 with more privacy
State or federal? protection will prevail.
MULTIPLE CHOICES |VERIFIED & REVISED
ANSWERS (NEW) 2026
Save
Terms in this set (56)
Purposes of medical record 1. To provide a communication tool between all
healthcare providers. A physician, nurse, and any
healthcare professional that treats the patient will
complete documentation within the medical
records
2. To provide documentation regarding diagnosis,
treatment, and care of the patient while to find a
receiving services from a healthcare facility.
3. To provide information needed for medical
billing of services rendered to the patient and
hospital financial management.
4. To provide a medium for analysis, study, and
evaluation of the quality of care given to a
patient.
5. To assist in protecting the legal rights of the
patients, the healthcare facility, and other
healthcare providers.
A master patient index (MPI) Tool gathered to obtain the complete medical
record. (Is electronic medical database that holds
information on every patient registered at a
healthcare organization.)
, Discharge summary Summary of treatment the patient received.
Includes the diagnosis of their ailment. This is
usually a transcribed report.
history and physical Reflects the history of the patients disease or
injury, as well as the history of treatment. Usually
transcribed, but may be hand written at the
beginning of the progress notes.
Electrocardiogram (EKG or ECG) & These are specialized tests for the heart (EKG)
electroencephalogram (eeg) and the brain (EEG) that produce strips of
findings that may be mounted on individual
pages.
Pulmonary function test (PFT) A test designed to measure how well the lungs
are working usually found in the respiratory
section.
Operative report This is a summary report of the operation
including a description of what was done and the
findings.
Pathology report An analysis of anything removed from the patient
during the operation (i.e. To check for cancer)
Continuity of care document (CCD) The CCD is generated from an electronic health
record (EHR). It is a summary data set with
demographic & clinical information about a
patients healthcare covering one of more
encounters.
Who owns the medical record? It is the property of the facility in which it was
created.
Which law is stronger if in conflict? Whichever is stricter than the 2 with more privacy
State or federal? protection will prevail.
