Chapter 2 : The Health Record

Question 1

What is a compilation of unique person and medical information relating to a client?

Answer 1

The medical record

Question 2

The medical record is what type of document?

Answer 2

a legal document

Question 3

What is the primary purpose of the health record?

Answer 3

the exchange of info among a client’s healthcare providers in order to determine problems, concerns, and strengths, plan and record treatment, substantiate care & fulfill legal documentation requirements

Question 4

The health record is the property of……

Answer 4

the health care facility

Question 5

HIPAA stands for……

Answer 5

Health Insurance Portability and Accountability Act (1996)

Question 6

What does POMR stand for……

Answer 6

Problem Oriented Medical Record

Question 6

What does POMR stand for……

Answer 6

Problem Oriented Medical Record

Question 7

What is used by healthcare providers when submitting claims for reimbursement?

Answer 7

billing codes

Question 7

What is used by healthcare providers when submitting claims for reimbursement?

Answer 7

billing codes

Question 8

What type of code enables healthcare providers to use common language?

Answer 8

CPT codes

Question 8

What type of code enables healthcare providers to use common language?

Answer 8

CPT codes

Question 9

What are the 2 types of CPT codes?

Answer 9

1) Level I

2) Level II

Question 9

What are the 2 types of CPT codes?

Answer 9

1) Level I

2) Level II

Question 10

What type of code is a 5 digit code maintained by the AMA and based on procedures?

Answer 10

Level I Codes (CPT)

Question 10

What type of code is a 5 digit code maintained by the AMA and based on procedures?

Answer 10

Level I Codes (CPT)

Question 11

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

Answer 11

Level II Codes (CPT)

Question 11

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

Answer 11

Level II Codes (CPT)

Question 12

What does ICD stand for?

Answer 12

International Classification of Diseases

Question 12

What does ICD stand for?

Answer 12

International Classification of Diseases

Question 13

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

Answer 13

ICD Codes

Question 13

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

Answer 13

ICD Codes

Question 14

What does POMR stand for……

Answer 14

Problem Oriented Medical Record

Question 15

What is used by healthcare providers when submitting claims for reimbursement?

Answer 15

billing codes

Question 16

What type of code enables healthcare providers to use common language?

Answer 16

CPT codes

Question 17

What are the 2 types of CPT codes?

Answer 17

1) Level I | 2) Level II

Question 18

What type of code is a 5 digit code maintained by the AMA and based on procedures?

Answer 18

Level I Codes (CPT)

Question 19

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

Answer 19

Level II Codes (CPT)

Question 20

What does ICD stand for?

Answer 20

International Classification of Diseases

Question 21

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

Answer 21

ICD Codes

Question 22

What does POMR stand for......

Answer 22

Problem Oriented Medical Record

Question 23

What is used by healthcare providers when submitting claims for reimbursement?

Answer 23

billing codes

Question 24

What type of code enables healthcare providers to use common language?

Answer 24

CPT codes

Question 25

What are the 2 types of CPT codes?

Answer 25

1) Level I | 2) Level II

Question 26

What type of code is a 5 digit code maintained by the AMA and based on procedures?

Answer 26

Level I Codes (CPT)

Question 27

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

Answer 27

Level II Codes (CPT)

Question 28

What does ICD stand for?

Answer 28

International Classification of Diseases

Question 29

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

Answer 29

ICD Codes