HIM final exam 1 | with complete solution | updated 2023/24

HIM final exam 1 | with complete solution | updated 2023/24 Which is an example of clinical data? - diagnosis An admissions clerk enters "right lower abdominal pain" as the admission diagnosis on the face sheet. This information is known as: - clinical data An inpatient record is typically between ____ in length. - 60 and 100 pages Between 1996 and 2006, the number of ambulatory care visits in the United States has: - increased A group practice usually consists of: - three or more physicians A form of authentication by an individual in addition to the signature by the original author is known as a(n): - countersignature Initials of care providers are typically used to authenticate entries on: - flow sheets and medication records The Joint Commission requires that the history and physical examination be documented in the patient record within ____ of inpatient admission. - 24 hours The Joint Commission requires patient records to be completed ____ days after a patient is discharged. - 30 An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the: - provisional diagnosis Which filing order saves time in processing discharged records? - universal chart order Tom Smith, a patient at Sunny View Hospital, fell out of his bed during his inpatient admission. An incident report was completed at the time of the fall. Smith is suing the hospital because he feels that the nurses were negligent when caring for him. The following actions were taken by the facility. Determine which of these actions should not have occurred. A. The incident report was filed in the risk management office. B. A note was entered in the patient record stating that an incident repor - B & C Sunny Valley Hospital uses the SOAP structure to document patient information. Observations about the patient would be documented in the ____ section of the progress note. - objective Which of the following record formats links all documentation to a specific problem? - problem-oriented Sunny Valley Hospital has an electronic health record system. The health information management (HIM) department has been asked by the quality management department to monitor the number of times that providers make corrections in patient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions? - audit trail Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient's record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the ____ data recorded in the record. - socioeconomic Dan Smith has recently moved to a new town. He calls Dr. Jones' office to make an appointment for an annual history and physical. It is the policy of Dr. Jones' office to have all new patients request information from their previous health care providers and forward copies to the office prior to their first visit. Dr. Jones reviews Dan's medical information, which includes treatment for alcohol abuse, depression, and documentation of therapy and treatment. This information would most accurately - behavioral health information Pre- and postanesthesia evaluations would be found in a(n) ____ record. - surgical care Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie's attending physician. Who must sign the history and physical? - Dr. Johns must sign the report first and then Dr. Blake must countersign.