Questions and Answers
IdentifyAtheAdocumentationAthatArecordsAtheAattendingAphysician'sAassessmentAofAtheApatien
t'sAcurrentAhealthAstatus.
PhysicalAexamination
MedicalAhistory
ProgressAnotes
DischargeAsummaryA-AAnswerAPhysicalAexamination
WhichAtypeAofAdataAidentifiesAtheApatientA(suchAasAname,AhealthArecordAnumber,Aaddress,A
andAtelephoneAnumber)?
AccessionAdata
IndicatorAdata
ReferenceAdata
DemographicAdataA-AAnswerADemographicAdata
CopiesAofApersonalAhealthArecordsA(PHRs)AareAconsideredApartAofAtheAdesignatedArecordAset
Awhen:
ConsultedAbyAtheAproviderAtoAgainAinformationAonAaAconsumer'sAhealthAhistory
UsedAbyAtheAorganizationAtoAprovideAtreatment
UsedAbyAtheAproviderAtoAobtainAinformationAonAaAconsumer'sAprescriptionAhistory
UsedAbyAtheAorganizationAtoAdetermineAaAconsumer'sADNRAstatusA-
AAnswerAUsedAbyAtheAorganizationAtoAprovideAtreatment
WhichAofAtheAfollowingArepresentsAtheArequiredAdocumentationAelementsAneededAtoAbeAinclu
dedAinAaApatient'sAhealthArecordAwhenAaAsurgicalAprocedureAisAperformed?
OperativeAreport,AanesthesiaAreport,ArecoveryAroomAreport
DischargeAsummary,AanesthesiaAreport,AoperativeAreport
RecoveryAroomAreport,AphysicalAtherapyAnotes,AoperativeAreport
, OperativeAreport,AdischargeAsummary,AanesthesiaAreportA-
AAnswerAOperativeAreport,AanesthesiaAreport,ArecoveryAroomAreport
TheAlinkAthatAtracksApatient,Aperson,AorAmemberAactivityAwithinAhealthcareAorganizationsAa
ndAacrossApatientAcareAsettingsAisAknownAas:
EnterpriseAmasterApatientAindexA(EMPI)
AuditAtrail
Case-mixAmanagement
ElectronicAdocumentAmanagementAsystemA(EDMS)A-
AAnswerAEnterpriseAmasterApatientAindexA(EMPI)
CancerAregistriesAareAmaintainedAbyAhospitals:
ByAfederalAlawAorAstateAlaw
VoluntarilyAorAbyAstateAlaw
VoluntarilyAorAbyAfederalAlaw
ByAmandateAfromAtheAAmericanACollegeAofASurgeonsA-AAnswerAVoluntarilyAorAbyAstateAlaw
WhichAofAtheAfollowingAisAaAcorrectAstatementAregardingADNRAorders?
AADNRAisAaAformAofAadvanceAdirectiveAandAonlyArequiresAtheApatient'sAdesireAforAtheAwith
holdingAofAcare.
TheArecordAshouldAbeAclearlyAmarkedAtoAindicateAtheApresenceAofAaADNRAorder.
AADNRAreplacesAtheAneedAforAanAadvanceAdirectiveAsinceAitAisAtheAultimateAinAadvanceAdir
ectiveAnotifications.
TheAPatientASelf-
DeterminationAActAisAfederalAsoAthereAareAnoAdifferencesAinAstateAlawAthatAneedAtoAbeAcon
sulted.A-
AAnswerATheArecordAshouldAbeAclearlyAmarkedAtoAindicateAtheApresenceAofAaADNRAorder.
ClinicalAdocumentationAsystemsAthatAsupportAclinicalAdecision-
makingAcaptureAdataAviaAwhichAofAtheAfollowing?
AlertingAprograms