Which of the following is a function of the health record?
*planning & managing care
*evaluating the adequacy & appropriateness of care
*substantiating reimbursement claims
*protecting the legal intersts of both the patient & healthcare provider
Which of the following clinical data elements is NOT usually documented in the acute care record?
Record of immunizations
Which of the following is NOT a function of the discharge summary?
Providing information about the patient's insurance company
In which of the following ways can the patient's consent to undergo treatment be expressed?
*by his or her submission to treatment
*by written agreement
*by vergal agreement
Which of the following would not be considered clinical data?
name of insurance company
Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?
The health insurance portability & accountability act (HIPAA)
Which of the following includes names of the surgeons & assistants, date, duration, & desription of the procedure & any specimens removed?
Which of the following is an ex. of an advance directive?
A living will
whichof the following materials is NOT documented in an emergency care record?
Patients complete medical history
Which of the following types of facility is NOT governed by MC long-term care documentation standards?
Assisted living facilities
Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?
Outcomes & assessment information set (OASIS)
Which regulations are the most commonly applied in end stage renal disease treatment?
Medicare Conditons for Coverage
Which of the following statements is NOT true of the process that should be followed in making corrections in paper-based health record entries?
The incorrect information should be obliterated
Which of the following types of healthcare facilities may seek accreditation from the Joint Commission?
*acute care hospitals
*home care providers
*ambulatory care organizations
The federal Conditons of Participation apply to which type of healthcare organization?
Any organization that treates MC or MA patients
Which of the following is NOT a traditional health record format?
Process-oriented health record
Which health records format is most commonly used by healthcare settings as they transition to electronic records?
Which of the following is NOT an example of data capture technology?
Which of the following is a challenge in the implementation of computer-based records?
*lack of standardization
*lack of clear definition
*organizational & behavioral resistance
*difficulty meeting the needs of multiple end users
Which of the following factors should be considered when designing a data retrieval system for an EHR?
Which is the end result of a review process that shows voluntary compliance with guidelines of an external, nonprofit organization?
Progress notes of physicians, nurses, therapists, or other authorized individuals would be found together in chronological order in what kind of paper record?
Which part of a medical history documents the nature & duration of the symptoms that caused a patient to seek medical attention as stated in the patients own words?
Which of the following creates a chronological report of the patients conditon & response to treatment during a hospital stay?
Which of the following determines who can receive & transcribe verbal orders?
medical staff bylaws