Unit 2 Test

Question 1

a voluntary process of institutional or organizational review in which a quasi-independent body creates for for this purpose periodically evaluates the quality of the entity’s work against preestablished written criteria

Answer 1

Accreditation

Question 2

a late entry added to a health record to provide additional information in conjunction with a previous entry. Late entry should be timely & bear the current date & reason why; Additional

Answer 2

Addendum

Question 3

a clarification made to healthcare documentation has been signed, it should be dated, timed, & signed; Clarification

Answer 3

Amendment

Question 4

process by which a duly authorized body evaluates & recognizes an individual, institution, or educational program as meeting predetermined requirements

Answer 4

Certification

Question 5

screening for medical necessity & the appropriateness & timeliness of the delivery of medical care from the time of admission until discharge

Answer 5

Concurrent review

Question 6

a patient’s acknowledgement that he or she understands a proposed intervention, including that intervention’s ricks, benefits & alternatives; Document signed by the patient that indicates agreement that protected health information (PHI) can be disclosed

Answer 6

Consents

Question 7

agreement that an individual makes to receive medical treatment, care or services (tests & examinations)

Answer 7

Consent to treatment

Question 8

documentation of the clinical opinion of a physician other than the primary or attending physician

Answer 8

Consultation report

Question 9

History, Physical, Discharge summary, Consultation report, Pathology report, Nursing notes, Progress notes, Physician orders, Consents

Answer 9

Contents of the medical record:

Question 10

an official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation

Answer 10

Deemed status

Question 11

a summary of the patient’s stay at a healthcare organization that is used along with post discharge plan of care to provide continuity of care upon discharge from the facility

Answer 11

Discharge summary

Question 12

a system of health record identification & storage that uses the patient’s last name as the first component of identification & his or her first name & middle name or initial for further definition

Answer 12

Filing system: Alphabetic filing system

Question 13

a health record filing system in which health records are arranged in ascending numerical order

Answer 13

Filing system: Straight-numeric filing system

Question 14

a system of health record identification & filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement

Answer 14

Filing system: Terminal-digit filing system

Question 15

How long is the MPI maintained:

Answer 15

Permanently

Question 16

How to correct an error in a paper medical record:

Answer 16

should be made by drawing a single line through the erroneous information & writing the word “error” above the mistake

Question 17

Identification (numbering) system-how the patient is linked to a medical record:

Answer 17

the health record number is created by the MPI & the numbers are issued in subsequential numeric order; A system of health record identification & storage in which records are arranged consecutively in ascending numerical order according to the health record number

Question 18

Information contained in the MPI:

Answer 18

patient demographics, dates of care, the patient’s health record number

Question 19

A legal term referring to a patient’s right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed; An individual’s voluntary agreement to participate in research or to undergo a diagnostic, therapeutic or preventive medical procedure

Answer 19

Informed consent

Question 20

a system of health record organization in which all the paper forms are arranged in strict chronological order & mixed with forms created by different departments

Answer 20

Integrated health record

Question 21

Know how to estimate space needed for shelving:

Answer 21

Evaluate volume indicators, such as number of discharges, size of records, & the capacity of the storage units

Question 22

a patient-identifying directory referencing all patients related to an organization, which also serves as a link to the patient record or information, facilitates patient identification, & assists in maintaining a longitudinal patient record from birth to death

Answer 22

Master patient index (MPI)

Question 23

portion of clinical data that addresses the patient’s current complaints & symptoms & list his or her past medical, personal, & family history

Answer 23

Medical history

Question 24

maintain chronological records of the patient’s initial vital signs & documentation of medications ordered & administered: summary of patient’s problems

Answer 24

Nursing notes

Question 25

the legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)

Answer 25

License

Question 26

source oriented, universal chart order, problem-oriented, integrated

Answer 26

Organization of records

Question 27

identifies where the health record is located & when it was removed; generally made of colored vinyl with 2 plastic pockets

Answer 27

Outguide

Question 28

filing patients alphabetically, keeping patient information & identifying patients on the shelf alphabetically

Answer 28

Paper based health record: Alphabetic

Question 29

system where a patient is issued a unique numeric identifier for every encounter at the healthcare facility; if a patient is admitted to the healthcare facility 5 times, he or she will have 5 different health record numbers

Answer 29

Paper based health record: Serial numbering system

Question 30

a combination of the serial & unit numbering systems; the patient is issued a new health record number with each encounter but all of the documentation is moved from the last number to the new number

Answer 30

Paper based health record: Serial-unit numbering system

Question 31

a health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters

Answer 31

Paper based health record: Unit numbering system

Question 32

a type of health record or documentation that describes the results of a microscopic & macroscopic evaluation of a specimen

Answer 32

Pathology report

Question 33

the physician’s assessment of the patient’s current health status after evaluating the patient’s physical conditions

Answer 33

Physical examination

Question 34

a physician’s written or verbal instructions to the other caregivers involved in a patient’s care

Answer 34

Physician orders

Question 35

patient record in which clinical problems are defined & documented individually

Answer 35

Problem-oriented health record

Question 36

the documentation of a patient’s care, treatment & therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient’s care, including nurses, physicians, therapists & social workers

Answer 36

Progress report

Question 37

to remove files of patients who have not been at the healthcare organization for a specified period, from the active filing area

Answer 37

Purge

Question 38

Purpose of the MPI

Answer 38

a numeric filing system which allows the user to look up the patient health record number so the record can be located

Question 39

a type of research conducted by reviewing records from the past (ex. birth/death certificates or health records) or by obtaining information about past events through surveys or interviews

Answer 39

Retrospective review

Question 40

a system of health record organization in which information is arranged accordingly to the patient care department that provided the care

Answer 40

Source-oriented health record

Question 41

documentation method that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments & plans

Answer 41

Subjective Objective Assessment Plan (SOAP) notes

Question 42

a system in which the health record is maintained in the same format while the patient is in the facility & after discharge

Answer 42

Universal chart order