1. Regardless of the healthcare setting, accreditation and regulatory standards require a separate
healthcare record for each ________________. - Answers individual patient
What type of standards do regulatory and accreditation standards represent? - Answers Minimal
Which of the following is not a purpose of healthcare records? - Answers Public education
The traditional medical record is synonymous with _______________. - Answers the electronic health
record
An electronic health record can have multiple versions, different views of displaying the same
information, and features that are not present in paper-based records. - Answers True
The healthcare industry lags behind other industries in the application of information technology in
communications and operations usage. - Answers True
Which of the following is not considered a healthcare provider and would not document clinical services
in the medical record? - Answers Health information administrator
The content and style of clinical documentation is influenced by all the following factors except
________________________. - Answers Status of the provider's license
Accreditation and regulatory standards require healthcare providers to create and maintain medical
records only for the inpatient setting. Physician offices and clinics do not have the same requirement. -
Answers False
Requirements for content of the medical record come from all of the following sources except: -
Answers AHIMA best practices
Health records are often called by different names. What factor determines the name that is used? -
Answers The healthcare setting
What is the primary purpose for documenting and maintaining medical records? - Answers Effective
communication among caregivers for continuity of care
Documentation consumer and family members' involvement in the consumer's treatment program is an
additional medical record purpose in what setting? - Answers Behavioral healthcare
Medical record documentation is guided by Medicare standards in which setting? - Answers Long-term
care
Health records and other documentation related to the patient care are the property of ___________. -
Answers The provider who created them