Questions Guaranteed 100% Pass
A core data set developed by ASTM to communicate a patient's past and current health
information as the patient transitions from one care setting to another is which of the following?
Continuity of Care Record
Minimum Data Set
Ambulatory Care Data Set
Uniform Hospital Discharge Data Set - CORRECT ANSWER ✔✔ -Continuity of Care Record
A family practitioner requests the opinion of a physician specialist in gastroenterology who
examines the patient and reviews the patient's health record. What type of report would the
physician specialist record his/her findings, impressions, and recommendations?
Consultation
Medical history
Physical examination
Progress notes - CORRECT ANSWER ✔✔ -Consultation
A health information technician is responsible for designing a data collection form to collect data
on patients in an acute-care hospital. Which of the following is the first resource she should use?
UHDDS
,UACDS
MDS
ORYX - CORRECT ANSWER ✔✔ -UHDDS
A healthcare system wants to analyze data from multiple computer systems across the
organization to determine trends in patient care services. Which of the following would be the
best application to perform this function?
Database
Data warehouse
Spreadsheet
WAN - CORRECT ANSWER ✔✔ -Data warehouse
A hospital is concerned about the difficulty in retrieving health records for patient care and legal
purposes. Some of its data are stored electronically while the remainder is stored on paper. The
hospital knows it will be several years before it will be able to implement an entire EHR system
and go paperless. Given this information, which of the following would be the best solution for
the hospital to ensure that all of the data for patient data is retrieved when needed?
Continue with the current system
Implement a document scanning system for storage of the paper record
Implement a microfilm system for storage and retrieval of the paper records
Implement a document scanning system for the paper records and interface data created in the
current EHR with the document scanning system - CORRECT ANSWER ✔✔ -Implement a
, document scanning system for the paper records and interface data created in the current EHR
with the document scanning system
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry.
No insulin reactions. Says she is following her diabetic diet." In which part of a problem-oriented
health record progress note would this be written?
Subjective
Objective
Assessment
Plan - CORRECT ANSWER ✔✔ -Subjective, entry relates significant information in the
patient's words of from the patient's point of view.
A notation for a hypertensive patient in a physician ambulatory care progress notes reads: "Blood
pressure adequately controlled." In which part of a problem-oriented health record progress note
would this be written?
Subjective
Objective
Assessment
Plan - CORRECT ANSWER ✔✔ -Assessment
A nurse is responsible for which of the following types of acute-care documentation?
Operative report