Health Record Content Exam Review

13 terms by CutieMcPretty 

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A discharge summary is required for all=

inpatient hospitalizations regardless of length of stay

Operative reports are to be documented within ______ after surgery=

24 hours

A pathology report is required=

whenever tissue (or other material) is removed

A provisional diagnosis is also known as a=

tentative diagnosis

Major sections of the history include=

past history, social history, chief complaint, present illness, and review of systems

A countersignature is a form of authentication by an individual in addition to the signature by the original author of an entry. It is mandated by=

state law

Health care services rendered must be documented to prove that care was provided and that good medical care is supported by patient record documentation. Therefore, inadequate patient record documentation may indicate=

poor health care delivery

Which of the following is NOT an administrative application of an electronic health record system=

medication administration record documentation

True or false, information is data that has been given meaning=

True

A long-term care hospital (LTCH) is defined in the Medicare law as a hospital that has an average inpatient length of stay (LOS) that is=

greater than 25 days

Long-term care services that provide assistance with activities of daily living (ADL) are associated with=

skilled care

Medicare does not usually reimburse=

residential care facility services

Rubber stamp signatures can be accepted by facilities if allowed by state and federal law. When rubber stamp signatures are authorized for use in a facility, a provider whose signature the rubber stamp represents must sign a statement that=

he or she alone will use the stamp to authenticate documents

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