Introduction to health care Mid-term

Question 1

Version control of documents int he EHR?

Accepted Answer

Policies and procedure to control which version is displayed

Question 2

When defining its legal health record, the provider organization must do which of the following

Accepted Answer

Assess the legal environment

Question 3

In a paper-based system, health records are organized in a standardized order know as what?

Accepted Answer

Assembly

Question 4

Specialized type of progress note provides detailed treatment action steps?

Accepted Answer

Care plan

Question 5

Hospitals that participate in the medicare and Medicaid programs much follow what?

Accepted Answer

The conditions of participation

Question 6

Which of the following is a tool used to track paper-based records?

Accepted Answer

Color coding

Question 7

Which group focuses solely on accreditation of rehabilitation program and services?

Accepted Answer

CARF

Question 8

Which of the following is an example of an institutional user of the health record?

Accepted Answer

Third-party Body

Question 9

The forms design committee does what?

Accepted Answer

provides oversight for the development of computer screens

Question 10

The acronym IDS refers to what?

Accepted Answer

Integrated Delivery Systems

Question 11

What enables the entry 101011963 to be displayed as 10/10/1963?

Accepted Answer

Input mask

Question 12

Written or spoken permission to proceed with care is classified as what?

Accepted Answer

Expressed consent

Question 13

Which of the following reports provides information on tissue removed during a procedure?

Accepted Answer

Pathology report

Question 14

Which of the following is an example of primary purpose of the health record?

Accepted Answer

Patient care

Question 15

What type of facility offers palliative care for end of life care.?

Accepted Answer

Hospice

Question 16

How are amendment's handled in the EHR?

Accepted Answer

Amendment must have a separate signature, date, and time

Question 17

Which of the following best describes Medicaid?

Accepted Answer

Federally mandated healthcare program for low income people

Question 18

What type of speech recognition is used when the physician edits the document?

Accepted Answer

Front-end

Question 19

Health departments use the health record to monitor outbreaks of diseases, which type is this?

Accepted Answer

Public health and research

Question 20

PT's address, current complaints and symptoms , past medical, personal/family history is listed

Accepted Answer

is in the medial history

Question 21

Who has the primary responsibility to guide the direction of the hospital?

Accepted Answer

Board of directors

Question 22

Which of the following is NOT an example of an administrative support service?

Accepted Answer

HIM

Question 23

Health departments use the health record to monitor outbreaks of diseases?

Accepted Answer

Public health and reseach

Question 24

Which of the following statements is true about registered nursed (RNs)?

Accepted Answer

They are required to have license in the state they work in

Question 25

An attending physician requests the advice of a second physician is known as what?

Accepted Answer

Consultation

Question 26

What manages cost, quality, and access to services?

Accepted Answer

Managed care

Question 27

Until the World War II, where was most healthcare provided?

Accepted Answer

Home

Question 28

Which of the following would NOT be found in a physical exam?

Accepted Answer

General condition

Question 29

The problem list is part of which of the following?

Accepted Answer

Problem-oriented health record

Question 30

One of the advantages of a DMS is that it can do what?

Accepted Answer

Control workflow

Question 31

A Pts registration forms, care plan, and discharge documentation is what type of health record

Accepted Answer

Long-term care

Question 32

A organization the utilized health record to prove or disprove efficacy of healthcare treatment

Accepted Answer

Research

Question 33

Reviewing a health record for missing signatures and missing medical reports is called what?

Accepted Answer

Analysis

Question 34

Which service diagnoses and treats patients who have acute and/or chronic lung disorders?

Accepted Answer

Respiratory therapy

Question 35

A patients gender, phone number, address, next of kin are all part of what?

Accepted Answer

Administrative data

Question 36

What feature of the filing folder helps locate misfiles within the paper-based filing system?

Accepted Answer

Color coding

Question 37

Which department does the HIM department interact to perform audits and monitor outcomes?

Accepted Answer

Quality improvement

Question 38

Which of the following is an example of an individual user?

Accepted Answer

Patient

Question 39

Nursing documentation within the health record will be what?

Accepted Answer

Both subjective and objective

Question 40

Which of the following is an example of a federally run hospital?

Accepted Answer

VA

Question 41

what microfilm format is inefficient when patient shave multiple admissions on microfilm?

Accepted Answer

Roll

Question 42

Which healthcare provider utilizes ultrasound, computed tomography, or MRIs?

Accepted Answer

Radiologic technologist

Question 43

Which federal agency monitors healthy precautions for international travelers?

Accepted Answer

CDC

Question 44

General documentation guidelines apply to what?

Accepted Answer

All categories of healthcare records

Question 45

Which of the following is an example of a primary purpose of the health record?

Accepted Answer

Patient care

Question 46

Paper based storage system conserves floor space by eliminating all bu one or two aisles?

Accepted Answer

Mobile filing units

Question 47

Two patient's records were filed together by mistake. this is an example of what?

Accepted Answer

Overlay

Question 48

Which of the following is a nonprofit, nongovernmental organization?

Accepted Answer

National Academy of Medicine

Question 49

Which of the following laws created the HITECH act?

Accepted Answer

American Recovery and Reinvestment act

Question 50

Which of the following is controlled by patients?

Accepted Answer

Personal health record

Question 51

Where will you find clinical decision support?

Accepted Answer

Electronic health record

Question 52

What type of health records may contain family and caregiver input?

Accepted Answer

Behavioral health records

Question 53

The ambulatory surgery record contains information most similar to which of the following?

Accepted Answer

Hospital operative records

Question 54

Which type of health record contains pt documentation in a setting of care to stabilize the Pt

Accepted Answer

Emergency care

Question 55

Which of the following is a risk of copying and pasting?

Accepted Answer

Copying the note in the wrong patient's record

Question 56

What electronic record allows paper-based health records to be incorporated into the Pts EHR?

Accepted Answer

Documentation-imaging technology

Question 57

Which healthcare professional assists physicians in clinical assessments and patient education?

Accepted Answer

Physician assistant

Question 58

Which of the following is the surgical specialty?

Accepted Answer

Orthopedics

Question 59

The subjective, objective, assessment, plan (SOAP) method came fro the what?

Accepted Answer

Problem-oriented health record

Question 60

The paper health record has been scanned and is now available digitally. what is this known for

Accepted Answer

It is known as imaging

Question 61

Which of the following medical practitioner is not considered a generalist?

Accepted Answer

Cardiology

Question 62

A patient history questionnaires, problem list, diagnostic test results are part of what?

Accepted Answer

Ambulatory record

Question 63

The overall goal of documentation standard is?

Accepted Answer

Ensure what is documented in the health record is complete

Question 64

A growth and development record may be found in what type of record?

Accepted Answer

Pediatric

Introduction to health care Mid-term

Questions 64

Introduction to health care Mid-term

Questions 64