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77 terms

WGU BDV1 Module 4

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Electronic Health Record (EHR)
A health record available electronically allowing communication across providers and permitting real-time decision making.
Hybrid Health Record
A health record that uses components of both paper and electronic systems.
Clinical and Adminstrative
What are the 2 parts of a health record?
Disease Management
Which of the following is a health record not used for? (Patient Care, Provider Commication, Evaluating Care, Disease Management, Substantiating Billing Claims, Legal Interests)
Government Reimbursement Programs
Which of the sources for standards documentaiton is missing? (Facility Standards, Licensure Standards, Accreditation Standards)
Medical History
Documents the patient's current complaints and symptoms and lists past medical, personal, and family history.
Physical Exam Report
Represents the attending Phy's assessment of the patient's current health status.
Progress Note
Documentaiton of clinical ovservations usually found in an acute care setting.
Implied Consent
This is assumed when a patient voluntarily submits to treatment.
Expressed Consent
This is in effect when consent is given either spoken or written.
Anesthesia Report
This document notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, duration of administration, and patient's vital signs while under anesthesia.
Operative Report
This document describes the surgical procedures performed on the patient and is dictated ot written by the surgeon following the procedure.
Recovery Room Report
This document includes the postanesthesia note, nurses's note regarding patient's condition, surgical site, vital signs, fluids given, and monitoring.
Discharge Summary
This document provides a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time of discharge from the hospital.
Discharge Summary
What documents the continuity of care, supports activities for medical staff review, and concise information used to answer requests for information by authorized indivudlas or entities.
Consent to treatment
This is obtained from patients or legal representatives before providing care or services in emergency situations.
Consent to treatment
Privacy legislation has made this document a matter of facility choice.
Notice of Privacy Practices (NPP)
The privacy rule requires providers to secure the patient's written acknowledgement that he or she has received this document.
Authorization to disclose information
This document allows the healthcare facilty to verbally disclose or send health informaiton to other organizations (other than those provided as part of HIPAA).
Advanced Directive
This is a legal document that contains the patient's choice for legal representative for healthcare purposes.
Do Not Resuscitate (DNR) and Do Not Attempt Intubation (DNI)
These physician orders should be consistent with the patient's advanced directives.
Patient's Bill of Rights
This regulation includes acknowledgment forms used to document the patient received information about their rights while a patient.
Medicare Conditions of Participation
This is another name for the Patient's Bill of Rights.
Licensure
What term refers to state or county regulations that healthcare facilities must meet to be permtted to provide care?
Care Plan
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment actin steps?
Newborn
An APGAR Score is likely found in what type of chart?
JCAHO
This organization issues specific health informaiton standards for acute care hopitals.
CARF
This organization issues specific health informaiton standards for rehab hospitals
Problem List
Ambulatory care records typically includes this document to facilitate ongoing patient care management, but it isn;t typically included on acute care records.
Problem List
This ambulatory care document describes current and past illnesses and conditions as well as procedures a patient has undergone.
Patient history questionnaire
Some physican practices use this to collect past medical history informaiton from the patient.
Accreditation Association for Ambulatory Health Care (AAAHC)
Name an accreditation agency that may have documentation standards for an ambulatory care setting?
JCAHO
Name an accreditation agency that may have documentation standards for an ambulatory care setting?
American Osteopathic Association (AOA)
Name an accreditation agency that may have documentation standards for an ambulatory care setting?
National Committee for Quality Assurance (NCQA)
Name an accreditation agency that may have documentation standards for an ambulatory care setting?
Obstetric/Gynecologic
Which type of record might include sexual practices?
Resident assessment instrument (RAI)
This care plan format is used by SNF's and includes the MDS.
Resident assessment protocols (RAPs)
The RAI includes MDS, triggers, utilization guidelines, and _______ ________ ________.
Minimum Data Set (MDS)
Medicare uses this form in a long term facility to determine reimbursement.
Outcomes and Assessment Informaiton Set (OASIS)
Medicare certified home health agencies use this standardized patient assessment insrutment for the plan of care and reimbursement.
Palliative Care
Care provided to terminally ill patients and supportive services to patients and families.
Patient assessment instrument (PAI)
This document is completed shortly after admisison and upon discharge to an inpatient rehab facility.
Conditions of Coverage
Medicare requires this for various settings of care for End-Stage Renal Disease.
Personal Health Record
An electronic, universally available, lifelong resource of health information needed by individuals to make health decisions.
Emergency Care
Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentaiton of care provided to stabilize the patient?
Ambulatory Care
Patient history quesionnaires, problem lists, diagnostic test results, and immunization records are found in which type od record?
Hospital operative records
Ambulatory surgery record contains information most similar to ___________.
Patient assessment instrument (PAI)
Which standardized tool is used to assess Medicare-certified rehab facilities?
Ambulatory care
Records in which setting would not include an interdisciplinary care plan?
Home Health and End-Stage Renal Disease
Portions of a treatment record may be maintained in a patient's home for which settings of care?
Long Term Care and Correctional Serevices
Paper records may require thenning in which two settings?
Continuous improvement and compliance, streamlined survey paperwork, midcycle reviews, sentinel events monitoring, and tracer methodology
In 2004 JCAHO implemented a new survey process called Shared Visions-New Pathways to bring what changes?
Management of Information
Accreditation manuals often include documentation standards in a section called what?
Ensure the quality of residency programs for their doctors.
The American Osteopathic Association (AOA) originally began for what purpose?
End-Stage Dialysis Centers
Which of these services are not accredited by CARF? (Medical Rehab, End-Stage Dialysis, Assisted Living, Behavorial Health, Adult day care, employment and community centers)
National Committee for Quality Assurance (NCQA)
What organization accreditates Managed Care and Preferred Provider Organizations starting in 1991?
Medicare Conditions of Participation
Organizations receiving funding for services to Medicare patients must comply with what?
30, 24
The Medicare Conditions of Participation requires that Medical History and Physical exam be completed no more than _____ days before or _____ hours after admission.
Objective section of a SOAP note
What is the correct section of the medical record to contain Vital Signs?
Social history of a Medical History
What is the correct section of the medical record to contain the marital status and occupation?
Plan section of a SOAP note
What is the correct section of the medical record to contain the referral of the patient to a physical therapist for treatment?
Review of systems portion of a Medical History
What is the correct section of the medical record to contain the Systematic Inventory?
Discharge Summary
What is the correct section of the medical record to contain the directions for follow up?
Joint Commission
What organization is the source of documentation standards or guidelines for Long Term Care facility?
AOA
What organization is the source of documentation standards or guidelines for Osteopathic residency programs?
AAAHC
What organization is the source of documentation standards or guidelines for Ambulatory care?
CARF
What organization is the source of documentation standards or guidelines for Rehabilitation hospital?
NCQA
What organization is the source of documentation standards or guidelines for Managed care assessment of in-plan providers?
Problem List
Which of the medical record form/report summarizes the patient's medical and surgical conditions?
Chief complaint or reason for visit
Which of the medical record form/report is a component of the medical history?
Operative Report
Which of the medical record form/report describes surgical procedures performed?
Consultation Report
Which of the medical record form/report is a written opinion provided by one physician to another?
Progress Note
Which of the medical record form/report an be integrated or source-oriented?
Subjective: Patient's complaints and comments
In a SOAP Note, what is the "S" represent?
Objective: Physical findings and laboratory data
In a SOAP Note, what is the "O" represent?
Assessment: Diagnosis and impression
In a SOAP Note, what is the "A" represent?
Plan: Medication, therapy, referral, consultation, and patient education
In a SOAP Note, what is the "P" represent?