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EXAM 2 HEALTH DATA
CONTENT.
A living will is a written document that informs a health care provider of a patient's desires regarding life-sustaining treatment. True False - CORRECT ANSWER - True Which of the following is documented on the physical examination? Denies loss of hearing. Patient's lungs are congested. Zocar, 40 mg, daily. "I'm feeling very tired lately." - CORRECT ANSWER - Patient's lungs are congested. All ancillary reports should be filed in the patient's record within 24 hours after interpretation of test results. True False - CORRECT ANSWER - true The major responsibility of a complete and accurate record rests with the: attending physician medical director medical staff committee director of HIM - CORRECT ANSWER - attending physician
Ms. RHIT is analyzing and assembling a patient's record and notices that a copy of a history and physical from the attending physician's office was used in the record instead of an inpatient history and physical. The office H&P was completed on January 2... acceptable, as the H&P for this admission because it was completed no more than seven days prior to admission unacceptable because the office H&P was not completed within 24 hours prior to admission. unacceptable because only a newly documented inpatient H&P is acceptable acceptable, as the H&P for this admission because it was placed on the record within 24 hours. - CORRECT ANSWER - acceptable, as the H&P for this admission because it was completed no more than seven days prior to admission Electrocardiogram (EKG) reports include a graphic printout of measurements of the electrical activity of the brain. True False - CORRECT ANSWER - False Which is an example of clinical data? Patient property form Informed consent Anesthesiology report Advance directive - CORRECT ANSWER - Anesthesiology report Dr. Smith documents in a patient's record that the patient may be released from the recovery room. This would be documented as part of the progress notes
financial record nursing assessment patient property form face sheet - CORRECT ANSWER - patient property form The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient weights on the day of admission as well as the day of discharge. This information can be located on the graphic record discharge summary nursing progress notes intake/output record - CORRECT ANSWER - graphic record Sally Jones assembles a patient record and organizes the following documents into a separate section of the record: face sheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered miscellaneous data administrative data financial data clinical data - CORRECT ANSWER - administrative data A patient was admitted with chronic obstructive pulmonary disease (COPD) on April 15 (this year). The patient has an exacerbation of COPD and was readmitted on June 1 (this year). The physician needs to document a(n)
progress note discussing patient's condition since April 15 history and physical examination short form history and physical examination interval history and physical examination - CORRECT ANSWER - history and physical examination Pre-and post-anesthesia progress notes are often documented on a special form to facilitate documentation by the anesthesiologist. True False - CORRECT ANSWER - True A document that informs a health care provider of a patient's desire regarding various life- sustaining treatment is a organ donation card do not resuscitate order health care proxy living will - CORRECT ANSWER - living will Molly Mapes was admitted to Sunny Valley Hospital on January 22 (this year) for pneumonia. The history and physical examination (H&P) was placed on the record January 24 (this year). Which of the following statements is true, based on Joint Commission standards? The record is not in compliance, as the H&P needs to be completed within 24 hours. The record is in compliance, as the H&P needs to be completed within 72 hours.
All entries must be legible and complete. Only the front page of a two-page document must contain patient identification - CORRECT ANSWER - All entries must be legible and complete. Dr. Smith wants to implement a new form to record postoperative complications. This should be reviewed to be approved for use in the medical record by the tissue committee medical director forms committee supervising operating room nurse - CORRECT ANSWER - forms committee An advance directive and an informed consent are considered clinical data. True False - CORRECT ANSWER - False Ready-to-use forms are often more expensive to purchase and therefore are used by few facilities. True False - CORRECT ANSWER - False Which of the following observations would be found in the physical examination report? Needs assistance to perform activities of daily living Review of systems negative for hypertension and diabetes
Has smoked two packs of cigarettes daily for past 30 years Abdomen soft and tender with no rebound tenderness - CORRECT ANSWER - Abdomen soft and tender with no rebound tenderness When a patient is transferred to a different level of care within the same hospital, the summary report is called a level of care summary transfer summary progress summary discharge summary - CORRECT ANSWER - transfer summary The forms committee oversees the process of new forms control and design. True False - CORRECT ANSWER - True Dr. Balby writes the following note: "Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant." This information would be documented as part of the postpartum record labor and delivery record antepartum record prenatal record - CORRECT ANSWER - labor and delivery record A patient is admitted for congestive heart failure and hypertension. During the admission, the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a
informed consent applied consent treatment consent patient consent - CORRECT ANSWER - informed consent The patient history documents the patient's chief complaint, history of present illness, past/family/social history, and review of systems. True False - CORRECT ANSWER - True A licensed nurse is required to have a public license to deliver care to patients. True False - CORRECT ANSWER - true Every report in the patient record must contain patient identification data. True False - CORRECT ANSWER - true Which of the following documents that the patient acknowledges the nature of treatment, risk, and complications of care? Consent History and physical Admission face sheet Discharge summary - CORRECT ANSWER - Consent Which of the following statements would be found as part of a preanesthesia note?
- The patient denies any previous reactions to anesthesia .2. General anesthesia is to be used.
- The patient had no reaction to current surgery.
- The patient is at risk due to smoking history. 2 and 3 1, 2, and 3 1 and 2 1, 2, and 4 - CORRECT ANSWER - 1, 2, and 4 Persons under 18 years of age must have their parents' or guardian's consent to donate organs. True False - CORRECT ANSWER - true The Health Care Financing Administration is now called the Centers for Medicare and Medicaid Services. True False - CORRECT ANSWER - true Dr. Jones reviews the following information located in the patient record. In which report is the information documented? Vital signs record History of present illness Physical examination Nursing care plan - CORRECT ANSWER - Vital signs record
True False - CORRECT ANSWER - false Progress notes facilitate health care team communication, which is crucial to quality care. True False - CORRECT ANSWER - true The hospital record that documents diagnostic, therapeutic, and rehabilitation services of outpatients is the discharge summary inpatient record ambulatory record short-stay summary - CORRECT ANSWER - ambulatory record Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Heart, a cardiologist, to evaluate Mary's chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the review of systems discharge summary report of consultation interval history and physical - CORRECT ANSWER - report of consultation Nurse Smith believes that inpatient Tom Jones needs physical therapy because his gait is unsteady when she works him. Which of the following would occur?
Nurse Smith would schedule Tom to be seen by the hospital physical therapist. Nurse Smith would discuss her observations with Tom's attending physician. Nurse Smith would begin bedside physical therapy for the patient. Nurse Smith would change the nursing care plan to include physical therapy. - CORRECT ANSWER - Nurse Smith would discuss her observations with Tom's attending physician. The Uniform Rules of Evidence states that for a record to be admissible in a court of law, all patient record entries must be dated and timed. True False - CORRECT ANSWER - True Which of the following would not be documented on a medication administration record? Nurse who administered medication Dosage given Medication given Provisional diagnosis - CORRECT ANSWER - Provisional diagnosis In which of the following cases would documentation of an interval history be acceptable? newborn admitted four days after birth for dehydration who is treated with IV fluids 34 - year-old woman readmitted for chest pain following delivery of a baby girl three days ago
principal diagnosis comorbidity chief complaint - CORRECT ANSWER - comorbidity Sally Smith is completing analysis of a patient's record and finds an original incident report in the record. Which action should she take? Send the original incident report to the risk manager's office Make a copy of the incident report for the patient's record, and send the original to the risk manager File the original incident report in the patient record Make a copy of the incident report for the risk manager, and file the original in the record - CORRECT ANSWER - Send the original incident report to the risk manager's office The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the Hospital Core Data Set Uniform Hospital Discharge Data Set Medicare/Medicaid Core Data Set Medicare/Medicaid Discharge Data Set - CORRECT ANSWER - Uniform Hospital Discharge Data Set The appearance of an outpatient to a hospital department is called an encounter. True
False - CORRECT ANSWER - false All orders must be authenticated by the responsible provider. True False - CORRECT ANSWER - true A delinquent record can result in suspension of a physician's medical staff privileges. True False - CORRECT ANSWER - true Clinical data contains all health care information obtained about a patient's care and treatment. True False - CORRECT ANSWER - true The role of a forms committee is to review all proposed forms to be used in the patient record. True False - CORRECT ANSWER - true As Ms. RHIT assembles and analyzes a discharged obstetrical patient's record, she finds the forms listed below. Which should be pulled from the discharged patient's record? A antepartum record (copy) Incident report and antepartum record (copy)
face sheet superslip fee schedule encounter form - CORRECT ANSWER - encounter form A complication is a preexisting condition that will cause an increase in the patient's length of stay by at least one day. True False - CORRECT ANSWER - false Sunny Valley Hospital has adopted the following patient record documentation guidelines: 2 and 5 1 and 2 1 and 4 2 and 3 - CORRECT ANSWER - 2 and 3 An APGAR score is documented in the nursing assessment autopsy report admission history and physical newborn record - CORRECT ANSWER - newborn record Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the medical staff
surgery committee forms committee executive board - CORRECT ANSWER - forms committee Upcoding or maximizing codes is considered DRG creep. True False - CORRECT ANSWER - true The Joint Commission standards require a patient's consent to treatment and require that the record contain evidence of consent. True False - CORRECT ANSWER - true The admitting diagnosis is the condition or disease for which the patient is seeking treatment. True False - CORRECT ANSWER - true The diagnosis that documents the condition or disease for which the patient is seeking treatment is the discharge diagnosis preoperative diagnosis provisional diagnosis final diagnosis - CORRECT ANSWER - provisional diagnosis The name of the attending physician is considered patient identification information. True
