HIM 201: Chapter 4 Workbook
Questions with 100% Correct 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. Correct Answer: Informed consent
b. Patient name, date of birth, patient gender, next of kin information Correct
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. Correct 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. Correct Answer: Notice of privacy practices
e. A patient states that he has experienced difficulty swallowing for the last two
weeks. Correct Answer: Medical history
f. Neck: supple. Carotid pulses 2/7. Slight Jugular venous distention is noted.
Correct Answer: Physical examination
g. 6-2-2014 Admit via internal medicine. Urinalysis, Cardiac diet. Correct 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. Correct Answer: Consultation
, i. Time: 0120 Temperature 36, Pulse 144, Respiration 46 Correct Answer: Vital signs
j. PT: 17.6 H, INR: 1.9, PTT: 32.0 H=High Correct 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 Correct Answer: Diagnostic report or imaging report
l. Date: 6/8/15 Surgeon: Dr. Anyone Assistant: None Anesthetic: Spinal
Complications: None Operation: Right Carotid Endarterectomy Correct Answer:
Operative report
m. Disposition: No lifting greater than 15 lbs. No driving for 6 weeks. Final
Diagnosis: Coronary Artery Disease Correct Answer: Discharge summary
n. Activity: Up in chair 0700 6/19/15 Hygiene: Shower Nutrition: 2/3 eaten IV
Pump: D/C Correct Answer: Progress note
o. 38 weeks gestation, Apgar's 8/9, 6# 9.8 oz. good cry, to room with mom
Correct Answer: Newborn record
Which of the following creates a chronological report of the patient's condition
and response to treatment during a hospital stay? Correct Answer: Progress
notes
Which health record format is most commonly used by healthcare settings as
they transition to electronic records? Correct Answer: Hybrid records
What is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization? Correct 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? Correct Answer: Chief complaint
Questions with 100% Correct 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. Correct Answer: Informed consent
b. Patient name, date of birth, patient gender, next of kin information Correct
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. Correct 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. Correct Answer: Notice of privacy practices
e. A patient states that he has experienced difficulty swallowing for the last two
weeks. Correct Answer: Medical history
f. Neck: supple. Carotid pulses 2/7. Slight Jugular venous distention is noted.
Correct Answer: Physical examination
g. 6-2-2014 Admit via internal medicine. Urinalysis, Cardiac diet. Correct 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. Correct Answer: Consultation
, i. Time: 0120 Temperature 36, Pulse 144, Respiration 46 Correct Answer: Vital signs
j. PT: 17.6 H, INR: 1.9, PTT: 32.0 H=High Correct 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 Correct Answer: Diagnostic report or imaging report
l. Date: 6/8/15 Surgeon: Dr. Anyone Assistant: None Anesthetic: Spinal
Complications: None Operation: Right Carotid Endarterectomy Correct Answer:
Operative report
m. Disposition: No lifting greater than 15 lbs. No driving for 6 weeks. Final
Diagnosis: Coronary Artery Disease Correct Answer: Discharge summary
n. Activity: Up in chair 0700 6/19/15 Hygiene: Shower Nutrition: 2/3 eaten IV
Pump: D/C Correct Answer: Progress note
o. 38 weeks gestation, Apgar's 8/9, 6# 9.8 oz. good cry, to room with mom
Correct Answer: Newborn record
Which of the following creates a chronological report of the patient's condition
and response to treatment during a hospital stay? Correct Answer: Progress
notes
Which health record format is most commonly used by healthcare settings as
they transition to electronic records? Correct Answer: Hybrid records
What is the end result of a review process that shows voluntary compliance with
guidelines of an external, non-profit organization? Correct 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? Correct Answer: Chief complaint
