problem oriented record
_________ consists of a database, problem list, initial plan, and SOAP notes.
signed, dated, timed
The Uniform Rules of Evidence states that for a record to be admissible in court, all patient record entries must be ____, ___, and ___.
parent's, guardian's consent
Persons under 18 years of age must have _____ or _____ to donate organs.
consent to treatment, evidence of consent
Joint Commission standards require a patient's _____ and that the record contain ____.
optional hospital services, medical record, outpatient
Medicare CoP categorizes outpatient care as _____ and requires the hospital to maintain a ____ for each ____.
An admission clerk enters "right lower abdominal pain" as the admission diagnosis on the face sheet. This information is known as
flow sheets, medication records
Initials of care providers are typically used to authenticate entries on ____ and ____.
source oriented records
The inpatient record format that is organized according to sections is called
The Joint Commission requires patient records to be completed ____ after a patient is discharged.
An admission clerk must obtain the reason for the admission (patient's chief complaint) when processing a hospital inpatient. This is called the
Sunny Valley Hospital uses the SOAP structure to document patient information. Observations about the patient would be documented in the _____ section of the progress note.
Dr. Johns, Dr. Blake
Dr. Johns is an unlicensed resident who performed a history and physical exam on Susie and also dictated the report. Dr. Blake is Susie's attending physician. _____ must sign the report first and then ____ must countersign.
Sunny Valley Hospital uses auto-authentication for transcribed records - a practice inconsistent with proper practices. In this process the physicians enter a unique identifier ____ the report is _____.
Sally Jones performs analysis of patient records and has identified several records with final diagnoses and procedures on the face sheet that differ from those documented elsewhere in the patient record. The type of analysis performed is
reverse chronological order
The physicians at Sunny Valley Hospital have requested that all progress notes be organizes with the most current progress note filed so as to be read first followed by the prior notes as it is filed while the patient is in house. This type of filing order is known as
The quality improvement committee wants to determine the number of patients that are admitted with a fever. The quickest way to locate this information would be to review the
An advance directive, informed consent, and patient property form are considered
Preexisting conditions that cause an increase in the patient's length of stay by at least one day in 75% of cases is known as
Uniform Hospital Discharge Data Set
The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the
A signed document that informs a health care provider of a patient's desire regarding various life sustaining treatment is
24 hours, 30 days
Medicare CoP and Joint Commission states that there must be a physical examination and health history completed and filed in the patient's record within ____ after admission and not more than ____ before admission.
The standards development organization that creates electronic health record standards under the direction of the U.S. Department of Health and Human Services is called
documented, signed, completed, blanks, names, numbers, black ink, specific, vague
Record completion requires that: (1) all entries should be ____ and ___ by author; (2) all entries should be _____ - no ____; (3) other patient ____ should not be documented in the record - only patient ____; (4) all documentation should be entered in _____; (5) all entries should be ____ and not ____.
A patient's record contains the following order: "Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks." This is an example of a
Dr. Health sees Molly in his office to monitor her blood chemistry. He completes an examination and orders blood test. His medical assistant completes the venipuncture. Charges for these services would be recorded on
The oncology committee has asked for data about patients admitted for chemotherapy. The committee wants to determine patient temperatures on the day of admission as well as day of discharge. This information can be located most easily on the
Dr. Sharp, a surgeon, has designed a new form that he wants to used when he completes cataract surgery. Approval of the form would be given by the
A 74 year old was readmitted for pneumonia seven days following discharge for this condition. In this case an ____ would be acceptable.
If a physician hears that the patient's lungs are congested, he would document it in the _____
Happy hospital uses the family numbering system. Tom Short is considered the head of household and is assigned patient number 01-345678. What number would his wife and third born child be?
Sunny Valley Hospital uses the serial numbering system. The master patient index card should contain all the _____ issued to the ____.
Terrace View Hospital is located in a community that has a large population of Hispanic and foreign patients. Which system can help facilitate the organization of the master patient index?
straight numeric filing
Ms. HIM files the following records: 223345, 223346, 223347, 223348. Which system is being used?
01-30-49, 02-30-49, 01-31-40, 02-36-40, 20-39-50, 03-40-50,
Arrange the following in middle digit order: 01-30-49, 01-31-40, 02-30-49, 02-36-40, 20-39-50, 03-40-50.
The HIM Department has purchased open shelf file and is now selecting folders. Which type of folders should be purchased?
Sunny View Hospital is part of a large university hospital with a very active and congested file area. Records are filed an refiled throughout the day. Which filing system should be used to distribute the records equally in the file area?
Sunny View Health Care Systems files the records for their clinics at the clinic sites, the ER records on the second floor, and the inpatient records on the fourth floor. The type of filing system used is
red and dark green
Hillcrest Hospital uses terminal digit numbering to file records and color codes just the primary number. Using the color pattern below what would be the color pattern for record number 39-09-15?
Color pattern: 0=orange, 1=red, 2=yellow, 3=purple, 4=light pink, 5=dark green, 6=dark pink, 7=light green, 8=brown, 9=black
The emergency room of Sunny View Hospital is located above the HIM department. The ER frequently requests records from the HIM department, The HIM Director wishes to purchases a mechanical circulation system device to transport records to the ER. Which system should be purchased?