Like this study set? Create a free account to save it.

Sign up for an account

Already have a Quizlet account? .

Create an account

Which of the following is a function of the health record?

- planning and managing care
- evaluating the adequacy and appropriateness of care
- substantiating reumbursement claims
- protecting the legal interests of both patient and provider

Which of the following clinical data elements is not usually documented in the acute care record?

Records of immunization.

Which of the following is not a function of the disharge summary?

Providing information about the patient's insurance coverage.

In which of the following ways can the patient's consent to undergo treatment be expressed?

- by their submission to treatment
- by written agreement
- by verbal agreement

Which of the following would not be considered clinical data?

Name of insurance company.

Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?

The Health Insurance Portability and Accountability Act

Which of the following includes names of the surgeon and assistants, date, duration and description of the procedure and any specimens removed?

Operative report.

Which of the following is an example of an advance directive?

A living will.

Which of the following materials is not documented in an emergency care record?

Patient's complete medical history.

Which of the following types of facility is not governed by Medicare long-term care documentation standards?

assisted living facilities

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

Outcomes and Assessment Information Set

Which regulations are most commonly applied in end stage renal disease treatment?

Medicare Conditions for Coverage

Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?

The incorrect information should be obliterated.

Which of the following types of healthcare facilities may seek accreditation from the Joint Commission ?

- acute care hospitals
- psychiatric hospitals
- home care providers
- ambulatory care providers

The federal Conditions of Participation apply to which type of healthcare organization?

Any organization that treats Medicare or Medicaid patients.

Which of the following is not a traditional health record format?

process-oriented health record

Which health record format is most commonly used by healthcare settings as they transition to electronic records?

hybrid records

Which of the following is not an example of a data capture technology?

data dictionaries

The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is:


Which of the following factors should be considered when designing a data retrieval system for an EHR?

- presentation of data
- quick search capabilities
- need to know
- analytical capabilities

What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?


Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) ____________ paper record.


Which part of a medical history documents the nature and duration of the
symptoms that caused a patient to seek medical attention as stated in that
patient's own words?

Chief complaint.

Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay?

Progress notes.

of the following determines who can receive and transcribe verbal orders?

Medical staff by-laws.

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions and try again


Reload the page to try again!


Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

Voice Recording