CRIS TEST questions and
answers 2025(graded A+)
Purposes of medical record - answer 1. To provide a communication tool
between all healthcare providers. A physician, nurse, and any healthcare
professional that treats the patient will complete documentation within
the medical records
2. To provide documentation regarding diagnosis, treatment, and care of
the patient while to find a receiving services from a healthcare facility.
3. To provide information needed for medical billing of services rendered
to the patient and hospital financial management.
4. To provide a medium for analysis, study, and evaluation of the quality of
care given to a patient.
5. To assist in protecting the legal rights of the patients, the healthcare
facility, and other healthcare providers.
A master patient index (MPI) - answer Tool gathered to obtain the
complete medical record. (Is electronic medical database that holds
information on every patient registered at a healthcare organization.)
Discharge summary - answer Summary of treatment the patient received.
Includes the diagnosis of their ailment. This is usually a transcribed
report.
history and physical - answer Reflects the history of the patients disease
or injury, as well as the history of treatment. Usually transcribed, but may
be hand written at the beginning of the progress notes.
Electrocardiogram (EKG or ECG) & electroencephalogram (eeg) - answer
These are specialized tests for the heart (EKG) and the brain (EEG) that
produce strips of findings that may be mounted on individual pages.
Pulmonary function test (PFT) - answer A test designed to measure how
well the lungs are working usually found in the respiratory section.
, Operative report - answer This is a summary report of the operation
including a description of what was done and the findings.
Pathology report - answer An analysis of anything removed from the
patient during the operation (i.e. To check for cancer)
Continuity of care document (CCD) - answer The CCD is generated from an
electronic health record (EHR). It is a summary data set with demographic
& clinical information about a patients healthcare covering one of more
encounters.
Who owns the medical record? - answer It is the property of the facility in
which it was created.
Which law is stronger if in conflict? State or federal? - answer Whichever is
stricter than the 2 with more privacy protection will prevail.
Examples of a breach of confidentiality - answer 1. Disclosing the wrong
patient's health information or wrong type of information or dates.
2. Releasing records without a valid authorization
3. Elevator, cafeteria, or hallway talk about private patient information
4. Faxing records to an incorrect fax number
5. Tossing discarded copies of the patient's record without shredding or
placement in a recycle bin
6. Taking records or copies of records home for personal use
7. Leaving records open on counters, desks and any unauthorized area
8. Discussing patient information with friends or family members
9. Incorrect writing of mail addresses on envelopes
10. Releasing any sensitive records without the special authorization that
may be required (drug, alcohol, HIV, mental health, genetic,etc)
11. Unauthorized access or viewing of computer terminals
12. Speaking loudly on the telephone or in the work area where someone
might overhear patient health information
answers 2025(graded A+)
Purposes of medical record - answer 1. To provide a communication tool
between all healthcare providers. A physician, nurse, and any healthcare
professional that treats the patient will complete documentation within
the medical records
2. To provide documentation regarding diagnosis, treatment, and care of
the patient while to find a receiving services from a healthcare facility.
3. To provide information needed for medical billing of services rendered
to the patient and hospital financial management.
4. To provide a medium for analysis, study, and evaluation of the quality of
care given to a patient.
5. To assist in protecting the legal rights of the patients, the healthcare
facility, and other healthcare providers.
A master patient index (MPI) - answer Tool gathered to obtain the
complete medical record. (Is electronic medical database that holds
information on every patient registered at a healthcare organization.)
Discharge summary - answer Summary of treatment the patient received.
Includes the diagnosis of their ailment. This is usually a transcribed
report.
history and physical - answer Reflects the history of the patients disease
or injury, as well as the history of treatment. Usually transcribed, but may
be hand written at the beginning of the progress notes.
Electrocardiogram (EKG or ECG) & electroencephalogram (eeg) - answer
These are specialized tests for the heart (EKG) and the brain (EEG) that
produce strips of findings that may be mounted on individual pages.
Pulmonary function test (PFT) - answer A test designed to measure how
well the lungs are working usually found in the respiratory section.
, Operative report - answer This is a summary report of the operation
including a description of what was done and the findings.
Pathology report - answer An analysis of anything removed from the
patient during the operation (i.e. To check for cancer)
Continuity of care document (CCD) - answer The CCD is generated from an
electronic health record (EHR). It is a summary data set with demographic
& clinical information about a patients healthcare covering one of more
encounters.
Who owns the medical record? - answer It is the property of the facility in
which it was created.
Which law is stronger if in conflict? State or federal? - answer Whichever is
stricter than the 2 with more privacy protection will prevail.
Examples of a breach of confidentiality - answer 1. Disclosing the wrong
patient's health information or wrong type of information or dates.
2. Releasing records without a valid authorization
3. Elevator, cafeteria, or hallway talk about private patient information
4. Faxing records to an incorrect fax number
5. Tossing discarded copies of the patient's record without shredding or
placement in a recycle bin
6. Taking records or copies of records home for personal use
7. Leaving records open on counters, desks and any unauthorized area
8. Discussing patient information with friends or family members
9. Incorrect writing of mail addresses on envelopes
10. Releasing any sensitive records without the special authorization that
may be required (drug, alcohol, HIV, mental health, genetic,etc)
11. Unauthorized access or viewing of computer terminals
12. Speaking loudly on the telephone or in the work area where someone
might overhear patient health information
