CH 25 Test Bank (Health Records & HIM)
Study online at https://quizlet.com/_8cw6kt
1. C: All of the following would be characteristics of a patient health record EXCEPT
it:
a. is a single record on a single patient only.
b. may be maintained in paper and/or electronic media.
c. is required for hospitals and emergency room visits only.
d. promotes communication among providers and continuity of care
2. B: A typical health information management department:
a. charges patients and doctors for its services and is a major revenue center for a
hospital.
b. is responsible for the maintenance, retrieval, and storage of health information.
c. is needed only in hospitals.
d. provides health records to physicians only.
3. D: The health information department performs which of the following supportive
functions?
1. Health research
2. Administrative activities of the organization
3. Publication of marketing literature for advertising
4. Support for medical education activities
5. Maintenance of a medical library for physicians and the general public
6. Patient billing and accounting processes
7. Quality management programs
a. 1, 2, 3, 6, and 7 only
b. 2, 3, 5, 6, and 7 only
c. 2, 4, 5, and 6 only
d. 1, 2, 4, 6, and 7 only
4. D: The shift to a prospective payment system (PPS) and diagnostic related groups
(DRGs) has made the health information process of _____ critically important to the
complete and timely reimbursement of medical costs provided by the government
(Medicare) and third-party payors.
a. duplication and copying
b. archiving
c. transcription
d. coding
5. D: Standards have been established for the maintenance of complete medical
records by the:
a. Joint Commission on the Accreditation of Healthcare Organizations (The Joint
Commission).
b. American Registry of Medical Records (ARMR).
1/5
, CH 25 Test Bank (Health Records & HIM)
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c. American Osteopathic Association (AOA).
d. Both a and c are correct.
6. A: Entering health information into a patient's medical record (charting) is com-
pleted by:
a. any department personnel who provide care to a patient.
b. physicians only.
c. nurses only.
d. health information managers only.
7. B: Health records for inpatients should contain what information?
1. Patient identification data
2. Number of patient visitors during the stay
3. Reports of any diagnostic or therapeutic studies
4. Physical examination data
5. Number of times the nurse call light is activated for nursing care
6. All informed consent documents
7. Medical history, including the chief complaint
a. 1, 2, 4, 6, and 7 only
b. 1, 3, 4, 6, and 7 only
c. 2, 3, 4, 5, and 7 only
d. 1, 4, and 6 only
8. C: As you and a colleague transport a patient back to the ER, the patient's fingers
get caught in the wheels of the wheelchair, but there is no apparent injury to the
patient. This event does require that an incident report be completed. The incident
report must be part of the:
a. patient's health record.
b. patient's medical history on discharge.
c. hospital's risk management documentation.
d. nurses' notes in the patient's chart.
9. D: As a radiographer working in a busy department, you have received an ex-
amination request for an interventional venous line placement for an inpatient. The
referring physician is very upset about any delay with his patient. In reviewing the
request, you notice that there is no indication as to why this examination is being
done. How would you proceed with this situation?
a. Complete the examination and get the missing information later.
b. Ask the patient if he knows why the examination is being done.
c. Because this patient is an inpatient, the missing information is unnecessary.
d. Delay the examination until the needed information is provided by the referring
physician.
2/5
Study online at https://quizlet.com/_8cw6kt
1. C: All of the following would be characteristics of a patient health record EXCEPT
it:
a. is a single record on a single patient only.
b. may be maintained in paper and/or electronic media.
c. is required for hospitals and emergency room visits only.
d. promotes communication among providers and continuity of care
2. B: A typical health information management department:
a. charges patients and doctors for its services and is a major revenue center for a
hospital.
b. is responsible for the maintenance, retrieval, and storage of health information.
c. is needed only in hospitals.
d. provides health records to physicians only.
3. D: The health information department performs which of the following supportive
functions?
1. Health research
2. Administrative activities of the organization
3. Publication of marketing literature for advertising
4. Support for medical education activities
5. Maintenance of a medical library for physicians and the general public
6. Patient billing and accounting processes
7. Quality management programs
a. 1, 2, 3, 6, and 7 only
b. 2, 3, 5, 6, and 7 only
c. 2, 4, 5, and 6 only
d. 1, 2, 4, 6, and 7 only
4. D: The shift to a prospective payment system (PPS) and diagnostic related groups
(DRGs) has made the health information process of _____ critically important to the
complete and timely reimbursement of medical costs provided by the government
(Medicare) and third-party payors.
a. duplication and copying
b. archiving
c. transcription
d. coding
5. D: Standards have been established for the maintenance of complete medical
records by the:
a. Joint Commission on the Accreditation of Healthcare Organizations (The Joint
Commission).
b. American Registry of Medical Records (ARMR).
1/5
, CH 25 Test Bank (Health Records & HIM)
Study online at https://quizlet.com/_8cw6kt
c. American Osteopathic Association (AOA).
d. Both a and c are correct.
6. A: Entering health information into a patient's medical record (charting) is com-
pleted by:
a. any department personnel who provide care to a patient.
b. physicians only.
c. nurses only.
d. health information managers only.
7. B: Health records for inpatients should contain what information?
1. Patient identification data
2. Number of patient visitors during the stay
3. Reports of any diagnostic or therapeutic studies
4. Physical examination data
5. Number of times the nurse call light is activated for nursing care
6. All informed consent documents
7. Medical history, including the chief complaint
a. 1, 2, 4, 6, and 7 only
b. 1, 3, 4, 6, and 7 only
c. 2, 3, 4, 5, and 7 only
d. 1, 4, and 6 only
8. C: As you and a colleague transport a patient back to the ER, the patient's fingers
get caught in the wheels of the wheelchair, but there is no apparent injury to the
patient. This event does require that an incident report be completed. The incident
report must be part of the:
a. patient's health record.
b. patient's medical history on discharge.
c. hospital's risk management documentation.
d. nurses' notes in the patient's chart.
9. D: As a radiographer working in a busy department, you have received an ex-
amination request for an interventional venous line placement for an inpatient. The
referring physician is very upset about any delay with his patient. In reviewing the
request, you notice that there is no indication as to why this examination is being
done. How would you proceed with this situation?
a. Complete the examination and get the missing information later.
b. Ask the patient if he knows why the examination is being done.
c. Because this patient is an inpatient, the missing information is unnecessary.
d. Delay the examination until the needed information is provided by the referring
physician.
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