HLST 2040 EXAM QUESTIONS AND
COMPLETE VERIFIED ANSWERS
\Q\.Patient Medical Record is now changed to - ANSWER-✔Patient Health Record-
Because it covers a holistic view of the patient.
\Q\.Acute Care Patient Record - ANSWER-✔Usually covers one stay or episode
\Q\.Outpatient Medical Record - ANSWER-✔Limited to one group or clinic
\Q\.Health Record - ANSWER-✔A legal document, it develops care plans for the
patient, improves the quality and processes of healthcare delivery, and is the basis
for improvements in health.
\Q\.Primary Records - ANSWER-✔These are gathered directly from the patient
and his or her provider, and is used for patient care and also as a legal document.
\Q\.Secondary Records - ANSWER-✔These are created later, by analyzing,
summarizing, or abstracting from the primary records. Secondary records are
used in billing , research, and quality improvement. These are also used for
reimbursement of insurance claims.
,\Q\.primary records term - ANSWER-✔electronic medical records, or paper forms.
they both have in common the patient's history and state of health, the physicians
observations, actions, tests, treatments and outcomes.
\Q\.Acute care hospital charts - ANSWER-✔contains admission and discharge
reports, nursing notes, physician examination notes, all orders, test results,
operative reports, pathology and radiology reports, and administrative and
demographic forms; nearly all are concerned with current stay.
\Q\.Ambulatory care facilities (physician offices) charts - ANSWER-✔They tend to
keep a single chart per patient, combining documents from all previous visits,
medical history, consults, lab results, and reports from other providers. It also has
insurance plan info.
\Q\.Home care agency records - ANSWER-✔centered on physicians orders for
treatment at home. Nurses and therapists keep notes from each visit.
\Q\.Dental records - ANSWER-✔Has abbreviated notes regarding treatments and
procedures performed. One chart covers all the visits, X-rays are small so they are
included in the charts.
\Q\.Master Patient Index (MPI) - ANSWER-✔Computerized system intended to
prevent duplication of registration per patient.
\Q\.Aggregate Data - ANSWER-✔Collected by gathering selected items of
information from many patients charts and then analyzing it.
, \Q\.Reasons for transition from paper to electronic records - ANSWER-✔Social
reasons
1) Patients move and change providers more frequently.
2) Records tend to be among different providers.
Practical reasons
1) Paper records cannot be easily accessed or shared.
2) The charts must be copied and faxed or transported from one office to another.
3) Handwritten parts are often abbreviated, cryptic, or illegible.
4) Time consuming- Searching paper files means that every file in a particular
section must be sorted through.
\Q\.Face Sheet - ANSWER-✔The patient demographics form in paper based
facilities.
\Q\.HIPAA Consent To Use and Disclose PHI - ANSWER-✔The patient
acknowledges receipt of the Notice of Privacy Practices. This consent may be
included in the registration form or combined with another consent form.
\Q\.Consent to Treatment - ANSWER-✔A general consent to be treated by the
healthcare practice or facility is usually included in the registration form.
Additional informed consent forms are needed for each operation or special
procedure.
COMPLETE VERIFIED ANSWERS
\Q\.Patient Medical Record is now changed to - ANSWER-✔Patient Health Record-
Because it covers a holistic view of the patient.
\Q\.Acute Care Patient Record - ANSWER-✔Usually covers one stay or episode
\Q\.Outpatient Medical Record - ANSWER-✔Limited to one group or clinic
\Q\.Health Record - ANSWER-✔A legal document, it develops care plans for the
patient, improves the quality and processes of healthcare delivery, and is the basis
for improvements in health.
\Q\.Primary Records - ANSWER-✔These are gathered directly from the patient
and his or her provider, and is used for patient care and also as a legal document.
\Q\.Secondary Records - ANSWER-✔These are created later, by analyzing,
summarizing, or abstracting from the primary records. Secondary records are
used in billing , research, and quality improvement. These are also used for
reimbursement of insurance claims.
,\Q\.primary records term - ANSWER-✔electronic medical records, or paper forms.
they both have in common the patient's history and state of health, the physicians
observations, actions, tests, treatments and outcomes.
\Q\.Acute care hospital charts - ANSWER-✔contains admission and discharge
reports, nursing notes, physician examination notes, all orders, test results,
operative reports, pathology and radiology reports, and administrative and
demographic forms; nearly all are concerned with current stay.
\Q\.Ambulatory care facilities (physician offices) charts - ANSWER-✔They tend to
keep a single chart per patient, combining documents from all previous visits,
medical history, consults, lab results, and reports from other providers. It also has
insurance plan info.
\Q\.Home care agency records - ANSWER-✔centered on physicians orders for
treatment at home. Nurses and therapists keep notes from each visit.
\Q\.Dental records - ANSWER-✔Has abbreviated notes regarding treatments and
procedures performed. One chart covers all the visits, X-rays are small so they are
included in the charts.
\Q\.Master Patient Index (MPI) - ANSWER-✔Computerized system intended to
prevent duplication of registration per patient.
\Q\.Aggregate Data - ANSWER-✔Collected by gathering selected items of
information from many patients charts and then analyzing it.
, \Q\.Reasons for transition from paper to electronic records - ANSWER-✔Social
reasons
1) Patients move and change providers more frequently.
2) Records tend to be among different providers.
Practical reasons
1) Paper records cannot be easily accessed or shared.
2) The charts must be copied and faxed or transported from one office to another.
3) Handwritten parts are often abbreviated, cryptic, or illegible.
4) Time consuming- Searching paper files means that every file in a particular
section must be sorted through.
\Q\.Face Sheet - ANSWER-✔The patient demographics form in paper based
facilities.
\Q\.HIPAA Consent To Use and Disclose PHI - ANSWER-✔The patient
acknowledges receipt of the Notice of Privacy Practices. This consent may be
included in the registration form or combined with another consent form.
\Q\.Consent to Treatment - ANSWER-✔A general consent to be treated by the
healthcare practice or facility is usually included in the registration form.
Additional informed consent forms are needed for each operation or special
procedure.
