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administrative data

Demographic, socioeconomic, and financial data

clinical data

All patient health information obtained throughout the treatment and care of patient.

demographic data

Patient identification information collected according to facility policy and includes the patient's name, date of birth, place of birth and social security number.

financial data

Any information relating to insurance or third party payer.


Type of data that includes marital status, occupation, and place of employment.


Type of data that includes date of birth, marital status, and insurance information


Type of data that includes information from the operative record, radiology report, and discharge summary.

source oriented record

Type of record where all documents generated from a particular department or discipline are located in one section of the record.


A source oriented record is ____________.

locate documents

Facilities use the source oriented record since its easy to _________.

follow one diagnosis, time consuming

Source oriented record is not ideal because it is difficult to ______ and filing reports can be _____.

problem oriented record

A systematic method of documentation consisting of four components.

database, problem list, initial plan, soap progress notes

The problem oriented record contains what four components?

progress note

In a problem oriented record, the discharge summary is documented in the ___________ section.

follow a diagnoses

Facilities may use a problem oriented record since its easy to _____.

training, time-consuming

The problem oriented record is not ideal because it requires _____ and filing of reports can be _____.


In a problem oriented record, this section contains a minimum set of date to be collected on every patient (chief complaint, present conditions, social data, past medical history, etc)

problem list

In a problem oriented record, this section acts as a table of contents for the patient record.

problem list

In a problem oriented record, this section is filed at the beginning of the record and contains a list of patient's problem.

initial plan

In a problem oriented record, this section outlines the strategy for management of the patient's care

initial plan

In a problem oriented record, this section describes actions that will be taken to learn more about the patient's condition and treat and educate the patient.

diagnostic/management, therapeutic, patient education

In a problem oriented record, the initial plan contains ______, ______, ______ plans.


In the POR, notes for each problem are documented using the _____ structure.


In the soap progress notes, this section is the patient's statement about how she, feels, including symptomatic information.


In soap progress notes, this section documents observations about the patient, such as physical findings or lab or x-ray results.


In soap progress notes, this section documents the judgment, opinion, or evaluation made by a health care provider.


In soap progress notes, this section documents the diagnostic, therapeutic, and educational plans to resolve the problems.

intent, driver's license, family members, parent or guardian consent, time of death

In order to be able to donate organs, the individual must indicate ______ to donate on a _____; individuals should inform _______ of their intentions; person's under 18 years old must have _____; and medical suitability for donation is determined at _____,

consent, evidence of consent

JC and CoP require that a patient ________ to treatment and that the record contain _____.

informed consent

JC requires facility medical staff and governing board to develop policies with regard to _____.


Provision of health care services by a physician whose opinion or advice is requested by another physician.

opinion, findings, physical exam, patient records

A consultation report includes consultant's _________ and _______ based on a __________ and review of _____.

patient record, examines, pertinent findings, recommendations, opinions

The consulting physician: (1) reviews _____; (2) _____ the patient; (3) documents _____; (3) provides _____ and _____.


This replaces the record in the file area to indicate it has been removed and to identify its current location.

patient record, outguide, chart tracking index box

In submitting a paper requisition, one copy of the requisition is attached to _____ and the other is inserted into the _____. The original stays in the _____.


These can be used in conjuction with computerized chart tracking systems to indicate "at a glance" that a record has been removed from the file area.

terminal digit

Type of filing system where number is divided into three parts: primary, secondary, and tertiary digits.

right, left

Terminal digit numbers are read from _____ to _____.

100, 100, straight numeric

The terminal and middle digit file system is typically divided into ____ primary sections, _____ secondary sections. Once primary and secondary sections are located, the record is filed in _____ order according to tertiary digit.


In terminal digit file system, tertiary numbers can be of ______ length.

middle digit filing

Type of filing systems where the middle digit is the primary, the digit on left is secondary, and digit on the right is tertiary.

serial numbering

Filing system where, each time the patient is registered, a new patient number is assigned by the provider and a new patient record is created.

patient numbers, multiple locations

In a serial numbering system, a patient who has had multiple admissions also has multiple _____. Patient records are also filed in ________ in the file system

security, evenly, congestion, large gaps, record shifting, misfiling, transposition, inactive records

Advantages to the terminal digit and middle digit filing system include: (1) high degree of _____; (2) files expand _____; (2) eliminates ______ in file area; (3) ______, _______, _____, and _______ occur less frequently; (6) _______ are easily retrieved as new records are added.

lengthier, space, equipment

Disadvantages to the terminal digit filing system include: (1) training time ______; (2) more _____ and ______ will be needed to organize file area.

serial numbering

This type of filing system is usually used by facilities that don't use computerized ADT software.


An advantage of the serial numbering system is that computer software is _____ needed to track assignment of numbers.

different, multiple locations

A disadvantage of a serial numbering system is that records are filed in ______ locations in the filing system. _______ must be accessed to retrieve patient records.

unit numbering

In this system, the patient is assigned a number the first time they are registered and are reassigned the same number for all subsequent admissions encounters.

unit numbering

In this type of system, multiple admissions/encounters requiring multiple volumes are secured together

serial unit numbering

Type of numbering system where patients receive a new number each time they are registered by the facility and records from previous admission/encounter are reassigned to new number.


The _____ of the entry is required to authenticate the entry in the record.

uniform rules of evidence

According to the _____ for a record to be admissible in a court of law, all patient records entries must be dated and timed.

dated, timed

For a record to be admissible in a court of law, all patient records entries must be ____ and ____.

30 days

Joint Commission requires the completion of medical record within _____ following patient discharge.

principal diagnosis

Condition established after study to be chiefly responsible for admission.

admitting diagnosis

The condition or disease for which the patient is seeking treatment.

provisional, preliminary, working, tentative

The admitting diagnosis is also called the _____, _____, ____, or _____ diagnosis.

preanesthesia evaluation note

Progress note documented by any individual qualified to administer anesthesia prior to induction of anesthesia.

medical history, experience with anesthesia, physical status, diagnostic studies, preanesthesia medications, anesthesia, surgical, obstetrical, problems, risks

A preanesthesia evaluation note contains: (1) patient interview to verify _____ and previous _______; (2) evaluation of patient's _____; (3) review of results from _____; (4) discussion of ________ and choice of _____ to be administered; (5) _____ or ______ procedures to be performed; (6) potential anesthestic ______ and _____.

postanesthesia note

A progress note documented by any individual qualified to administer anesthesia following surgery.

general condition, complications, abnormalities, vital signs, swallowing, cyanosis

A postanesthesia evaluation note contains: (1) patient's ______ following surgery; (2) description of anesthesia related ______ and postoperative _____; (3) _____; (4) ______ reflex and _____.

chief complaint, history of present illness, past, family, social, medications, review of systems

The patient history documents ______, ________, ______/______/______ history, _____, and _____.

physical exam

Assessment of the patient's body systems to assist in determining a diagnosis

auto authentication

Process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specific time results in authentication.

legal liability, noncompliant

Auto authentication presents a _____ for the health care organization and is likely to be _____ with federal and state requirements.

joint commission

Auto-authentication does not comply with _____ standards.

quantitative analysis

Review of the patient record for completeness, including identification of chart deficiencies.

quantitative analysis

When the record is being reviewed for the presence of reports and authentications, a _____ is being done.

qualitative analysis

Review of the patient record for inconsistencies that may identify incomplete or inaccurate documentation.

qualitative analysis

When the record is being reviewed for final diagnoses or procedures on the face sheet.

reverse chronological order

Documents are organized from the most current document to least current document.

chronological order

Documents are organized from least current to most current document.

reverse chronological order, chronological order

Most facilities organize the patient record in _______ during inpatient hospitalization, and ________ once patient is discharged.

nursing assessment

Upon admission to the hospital, this is documented to obtain the patient's history and evaluate vital signs.

nursing documentation

This type of documentation contains a nursing assessment, administration of meds, observations and progress, and a discharge plan.

nursing care plan

Documents nursing interventions to be used to care for patient.

nurses notes

Documents daily observations about patient by nurses.

nursing discharge summary

Patient discharge plans and instructions as documented by a nurse.

graphic sheet

Document's a patient's vital signs using a graph for easy interpretation of data.

type, time, date, initials

The medication administration record documents the ______ of medication administered, ______ and _____ of administration, and _______ of nurse administering the medication.

nursing assessment, nutritional, functional, 24 hours

With regard to nursing, the JC requires that a __________, ________ screening, and ________ screening needs to be done within _____ after admission.

initial history, reaction to treatment, treatments rendered

Nurses notes include ________, ________, and ______.

advance directive

Hospitals are required to notify patients age 18 and over that they have the right to have an ________.

patient self determination act

This required that hospital notify patients of their right to have an advance directive.

advance directive notification form

Upon admission, the patient signs an _________ to document that the patient has been notified of their right to have an advance directive.

advance directive

A legal document in which patients provide instructions as to how they want to be treated in the event they become ill and there is no reasonable hope for recovery.

advance directives, implementation, advance directives

Facilities must inform patients, in writing, of state laws regarding ______ and facility policies regarding _______ of ________.

advance directive

The patient record must document whether the individual has executed an _______.

do not resuscitate order

Advance directive that indicates medical professionals should not perform cardiopulmonary resuscitation in the event that breathing or heartbeat stops.

CPR, transfer

If the patient is at home or in a nursing home, a DNR order tells medical personnel to not perform _________ and not _______ the patient to hospital.

living will

Advance directive that indicates the kind of health care patient does or does not want under certain circumstances as well as patient's desires for life sustaining treatment.

health care durable power of attorney

Advance directive where patient names someone close to them to make decisions about health care in the event they become incapacitated.

cardiac arrest

Hospital DNR orders tell the medical staff not to revive patient if _____ occurs.


Pre-existing condition that will, because of its presence with a specific principal diagnosis, cause an increase in patient's length of stay.


Additional diagnoses that describe conditions arising after the beginning of treatment and that modifies the course of patient's illness or medical care.

treatment options, patient's diagnosis, treatment/surgery, reason for, complications, success, risks

Informed consent involves the process of advising patient about _____ and disclosure of _____, proposed _____, _____ treatment/surgery, possible _____, likelihood of _____, and _____ if they do not undergo treatment.

risks, benefits, alternatives, understands, consents

An informed consent entry should include an explanation of ________ and _______ of treatment/procedure, _________ to treatment/procedure, and evidence that the patient _______ and _________ to undergo treatment/procedure.

chief complaint

Patient's description of their medical condition in their own words.

history, database, emergency record, discharge summary

Chief complaint is documented in the _____ or, in the POR, the _____. It is also located in the _______ and _____.

uniform ambulatory care data set

This is the minimum core data set collected on Medicare and Medicaid outpatients.

uniform hospital data discharge set

The minimum core data set collected on individual hospital discharges for Medicare and Medicaid.


Both UACDS and UHDDS are maintained by ______.

30, 24 hrs

JC and CoP requires a complete physical exam to be performed no more than _______ days prior to admission or within ______ after admission

neonatal record

Newborn's record containing the birth history, newborn identification, physical exam, and progress notes.

birth history

This is a summary of pregnancy, labor and delivery, and newborn's condition upon birth.

newborn identification

This contains newborn's footprints and fingerprints.

newborn progress notes

These contain information gathered by nurses in the nursery including vital signs, skin color, intake and output, weight, medications and treatments, and observations.

newborn physical exam

An assessment of the newborn's condition immediately after birth including time and date of birth, vital signs, birth weight, head and chest measurements, general appearance, and physical findings.

newborn notes

These contain information gathered by nurses in the nursery.

autopsy report

This documents macroscopic/ microscopic exam of vital organs and tissue specimens to determine cause of death and extent of disease.

patients clinical history, macroscopic, microscopic, external appearance, internal examination, contributing factors, clinical pathologic, authentication

Elements of the autopsy report include: (1) summary of ________; (2) detailed results of ________ and ______ findings, including ______ and _______ by body system; (3) __________ that led to death; (4) __________ correlation; (5) _______ by pathologist.

health information manager

This person is responsible for educating physicians/health care providers about proper documentation procedures and policies.

attending physician

The major responsibility for an adequate patient record rests with the _____.

attending physician

This person is responsible for performing an admission history and physical exam on the patient in a hospital.

attending physician

This person is responsible for dictating a discharge summary to document care provided to patient during inpatient hospitalization.

health information managers

This person ensures the delivery of quality health care.

color coding

The assignment of color to primary (and maybe secondary) patient numbers or letters used for filing patient records.

sides, edges

In color coding, color bars are placed on the ______ or _____ of file folders.

same, misfiling

Primary and secondary numbers have _____ color pattern. This prevents ______.


The most common approach is to assign color codes to the _____ number used for filing.

discharge order

Final physician order documented to release a patient from a facility.

encounter form

Commonly used in physician offices to capture charges during an office visit; consists of a single page containing a list of common services.


An encounter form is also known as a _____.

patient identification, financial data, diagnosis, office procedures, lab tests, injections

An encounter form consists of _____, _____, _____, _____, _____, and _____.

reasons for hospitalization, diagnoses, procedures, findings, treatment, services, condition, instructions

A discharge summary documents the _____; _____; _____ performed; _____, _____, and _____ provided; patient's _____ at discharge; and _____.

health information

Forms control and design is usually the responsibility of the ________ department.

forms committee

This is sometimes established to oversee the control, design, and approval of forms.

interval history

Documents a patient's history of present illness and any pertinent changes and physical findings that occurred since a previous inpatient admission if patient was readmitted within 30 days after discharge for same condition.

30 days, same condition

An interval history can only be done if the patient was readmitted within _____ after discharge for _____.

original, attending physician

With regard to an interval history, the ______ must be made available to _____.

obstetrical record

Mother's record containing an antepartum record, labor and delivery record, and postpartum record.

antepartum record

This is started in the physician's office and includes the health history of the mother, family and social history, pregnancy risk factors, care during pregnancy, medications, etc.

labor and delivery record

This details the progress of the mother from the time of admission through the time of delivery.

labor and delivery record

Includes time of onset contractions, severity of contractions, medications, vital signs, and progression of labor.

postpartum record

This provides information concerning the mother's condition after delivery.

master patient index

Facility keeps a _____ used to locate a patient's record.

master patient index

Links a patient's medical record number with common identification elements.

master patient index

In physician offices that do not assign medical record numbers, a ______ is not necessary.


Phonetic indexing systems that allows surnames that sound alike, but are spelled differently, to be filed together.

master patient index cards, foreign sounding names

Soundex has been adopted by health care facilities to organize _________ in communities with large populations of _________.

sound, sound alike, spelled differently

In the soundex system, MPI cards are filed according to _____ rather than spelling; surnames that _____ but are _____ are filed together.

open shelf file

Type of file that resembles a bookshelf; a six to eight shelf unit.

twice, drawer file cabinet, 10%

Open shelf file provides ______ as much filing space as standard ________ and requires less than _____ additional floor space.

end tab

Open shelf file uses ______ folders.

lateral file

Two to eight shelf unit with retractable doors.

top tab

Lateral file uses _____ folders.

movable file

Type of file mounted on a track and are moved by manual hand crank or motorized systems

end tab

Movable files use _____ folders.

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