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Chapter 3

1. Which of the following is not an example of a long-term care setting?
A) Community mental health centers
B) Nursing homes
C) Subacute care organizations
D) Assisted living facilities

A) Community mental health centers

2. The number of ligatures sutures, packs, drains, and sponges used and specimens removed would be found in the:
A) Progress notes
B) Operative report
C) Recovery room report
D) Anesthesia report,

B) Operative report

3. Which of the following is an example of clinical data?
A) Date and time of admission
B) Admitting diagnosis
C) Insurance information
D) Health record number

B) Admitting diagnosis

4. Which type of patient care record includes documentation of a family bereavement period?
A) Hospice record
B) Ambulatory care record
C) Home health record
D) Long-term care record

A) Hospice record

5. Which of the following organizations drafted more than 130 functional standards for electronic health records?
A) International Standards Organization
B) American Health Information Management Association
C) Health Level Seven (HL7)
D) National Library of Medicine

C) Health Level Seven (HL7)

6. Which of the following is true of computer-based records?
A) Is usually supported by all healthcare providers
B) Can be accessed by multiple end users simultaneously
C) Permits minimal risks to healthcare privacy and security
D) Uses clear, consistent content standards,

B) Can be accessed by multiple end users simultaneously

7. Which of the following is an advantage of paper-based records?
A) Duplicates commonly maintained
B) Easy to update
C) Resists damage
D) Standardized familiar format

D) Standardized familiar format

8. Which of the following represents the attending physician's assessment of the patient's current health status?
A) Progress notes
B) Medical history
C) Physical examination
D) Discharge summary

C) Physical examination

9. Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?
A) American Osteopathic Organization
B) Joint Commission
C) Accreditation Association for Ambulatory Healthcare
D) Commission on Accreditation of Rehabilitation Facilities

D) Commission on Accreditation of Rehabilitation Facilities

10. Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?
A) Home health
B) Rehabilitative care
C) End-stage renal disease
D) Behavioral health,

A) Home health

11. A nurse is responsible for which of the following types of acute care documentation?
A) Operative report
B) Radiology report
C) Therapy assessment
D) Medication record

D) Medication record

12. Which accrediting organization has instituted unannounced surveys and requires submission of annual performance reviews?
A) American Osteopathic Association
B) Accreditation Association for Ambulatory Healthcare
C) Commission on Accreditation of Rehabilitation Facilities
D) Joint Commission

D) Joint Commission

13. Which type of specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?
A) Ambulatory surgery record
B) Emergency care record
C) Pediatric record
D) Ambulatory care record

B) Emergency care record

14. Which of the following is an example of an advance directive?
A) Authorization to disclose information
B) Patient's bill of rights
C) Living will
D) Notice of privacy practices

C) Living will

15. The attending physician is responsible for which of the following types of acute- care documentation?
A) Discharge summary
B) Pathology report
C) Consultation report
D) Laboratory report

A) Discharge summary

16. "The patient indicates that she is dizzy nauseous, and feels her throat tightening." This entry would be recorded in which section of a SOAP note?
A) Plan
B) Assessment
C) Subjective
D) Objective,

C) Subjective

17. In a medical history which of the following is a detailed chronological description of the development of the patient's illness?
A) Review of systems
B) Present illness
C) Past medical history
D) Chief complaint,

B) Present illness

18. An RAI/MDS and care plan are found in records of patients in:
A) Home healthcare
B) Long-term care
C) Behavioral healthcare
D) Rehabilitative care

B) Long-term care

19. Which of the following contains the physician's findings based on an examination of the patient?
A) Discharge summary
B) Patient instructions
C) Medical history
D) Physical exam

D) Physical exam

20. What is the general name for Medicare standards impacting healthcare organizations?
A) Conditions of Participation
B) Terms of Accreditation
C) Regulations for Licensure
D) Requirements for Service

A) Conditions of Participation

21. Which of the following is not usually a component of acute care patient records?
A) Progress notes
B) Nurse assessment
C) Problem list
D) Medical history

C) Problem list

22. Documentation standards and guidelines are published by a variety of private and public organizations including the:
A) National Committee for Quality Assurance
B) Joint Commission
C) American Health Information Management Association
D) All of the above,

D) All of the above,

23. When correcting erroneous information in a paper health record which of the following is not appropriate?
A) Print "error" above the entry.
B) Enter the correction in chronological sequence.
C) Add the reason for the change
D) Use black pen to obliterate the entry.,

D) Use black pen to obliterate the entry.,

24. In which setting may treatment records travel with the patient between treatment centers?
A) Behavioral healthcare
B) Correctional facility care
C) Long-term care
D) Ambulatory care

B) Correctional facility care

25. Which type of health record is designed to measure clinical outcomescollect data at the point of care, and provide medical alerts?
A) Problem-oriented record
B) Electronic record
C) Paper record
D) Hybrid record,

B) Electronic record

26. Which of the following represents documentation of the patient's current and past health status?
A) Patient consent
B) Physical exam
C) Physician orders
D) Medical history

D) Medical history

27. Documentation of genetic information immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record?
A) Personal health record
B) End-stage renal disease record
C) Correctional facility health record
D) Long-term care record,

A) Personal health record

28. Patient history questionnaires are most often used in:
A) Long-term care
B) Ambulatory care
C) Rehabilitative care
D) Home healthcare

B) Ambulatory care

29. What is the function of a consultation report?
A) Documents the physician's instructions to other parties involved in providing care to a patient
B) Provides a chronological summary of the patient's medical history and illness
C) Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care
D) Concisely summarizes the patient's treatment and stay in the hospital.

C) Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

30. What is the function of physician's orders?
A) To document the physician's instructions to other parties involved in providing care to a patient
B) To provide a chronological summary of the patient's illness and treatment
C) To document the provider's instructions for follow-up care given to the patient or patient's caregiver
D) To document the patient's current and past health status

A) To document the physician's instructions to other parties involved in providing care to a patient

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