HIMT 1100 Midterm UPDATED ACTUAL
Exam Questions and CORRECT Answers
False - CORRECT ANSWER - A complication is a preexisting condition that will cause an
increase in the patient's length of stay by at least one day.
False - CORRECT ANSWER - A consent to admission documents a patient's consent for
all medical treatment including procedures and surgeries to be completed during the current
admission.
True - CORRECT ANSWER - A consultation includes the examination of a patient by a
specialist, who also provides an opinion or advice
True - CORRECT ANSWER - A delinquent record can result in a suspension of a
physician's medical staff privileges.
True - CORRECT ANSWER - A discharge progress note can be documented in a patient
record instead of a discharge summary if a patient had an uncomplicated hospital stay of less
than 48 hours
True - CORRECT ANSWER - A licensed nurse is required to have a public license to
deliver care to patients
True - CORRECT ANSWER - A living will is a written document that informs a health
care provider of a patient's desires regarding life-sustaining treatment
Comorbidity - CORRECT ANSWER - 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:
History and Physical examination - CORRECT ANSWER - 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):
Discharge order - CORRECT ANSWER - A patient's record contains the following order,
"Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No
medications given and no restrictions. She can be release home in the morning. To be seen in my
office in two weeks." This is an example of a:
Comorbidity - CORRECT ANSWER - A preexisting condition that causes an increase in
the patient's length of stay by at least one day in 75% of the cases is known as a:
True - CORRECT ANSWER - A principal procedure is performed for definitive or
therapeutic reasons.
True - CORRECT ANSWER - All ancillary reports should be filed in the patient's record
within 24 hours after interpretation of test results.
True - CORRECT ANSWER - All orders must be authenticated by the responsible
provider.
True - CORRECT ANSWER - American Osteopathic Association (AOA) requirements
state that a patient record must be maintained for each patient treated in the emergency
department.
Newborn record - CORRECT ANSWER - An APGAR score is documented in the:
False - CORRECT ANSWER - An admission note documented by the attending physician
can replace a dictated history and physical examination .
False - CORRECT ANSWER - An advance directive and an informed consent are
considered clinical data.
, Review of Systems (ROS) - CORRECT ANSWER - An inventory of body systems to
reveal subjective symptoms stated by the patient is called the __________.
state departments of health or offices of vital statistics - CORRECT ANSWER - Birth
certificate information is usually submitted to the ______ within 10 days of birth.
Labor and delivery record - CORRECT ANSWER - 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:
Differential diagnoses - CORRECT ANSWER - Dr. Cook records the following as part of
a history and physical examination: "Patient presents with abdominal pain of seven days'
duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out
appendicitis vs. obstruction of colon." The diagnoses recorded are:
Encounter form - CORRECT ANSWER - Dr. Health sees Jack in her office to monitor his
blood chemistry. She completes an examination and orders blood tests. Her medical assistant
completes the venipuncture. Charges for the services would be recorded on an:
Chief complaint - CORRECT ANSWER - Dr. Jones completes an admission history and
physical on Bob Lot, who states, "when I walk upstairs, I have difficulty breathing." This
statement is known as the patient's
Report of consultation - CORRECT ANSWER - 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. Hart, a cardiologist, to evaluate Mary's chest pain. Dr. Hart would
document his examination of the patient, pertinent findings, recommendations, and opinions on
the:
Forms committee - CORRECT ANSWER - 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:
Exam Questions and CORRECT Answers
False - CORRECT ANSWER - A complication is a preexisting condition that will cause an
increase in the patient's length of stay by at least one day.
False - CORRECT ANSWER - A consent to admission documents a patient's consent for
all medical treatment including procedures and surgeries to be completed during the current
admission.
True - CORRECT ANSWER - A consultation includes the examination of a patient by a
specialist, who also provides an opinion or advice
True - CORRECT ANSWER - A delinquent record can result in a suspension of a
physician's medical staff privileges.
True - CORRECT ANSWER - A discharge progress note can be documented in a patient
record instead of a discharge summary if a patient had an uncomplicated hospital stay of less
than 48 hours
True - CORRECT ANSWER - A licensed nurse is required to have a public license to
deliver care to patients
True - CORRECT ANSWER - A living will is a written document that informs a health
care provider of a patient's desires regarding life-sustaining treatment
Comorbidity - CORRECT ANSWER - 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:
History and Physical examination - CORRECT ANSWER - 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):
Discharge order - CORRECT ANSWER - A patient's record contains the following order,
"Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No
medications given and no restrictions. She can be release home in the morning. To be seen in my
office in two weeks." This is an example of a:
Comorbidity - CORRECT ANSWER - A preexisting condition that causes an increase in
the patient's length of stay by at least one day in 75% of the cases is known as a:
True - CORRECT ANSWER - A principal procedure is performed for definitive or
therapeutic reasons.
True - CORRECT ANSWER - All ancillary reports should be filed in the patient's record
within 24 hours after interpretation of test results.
True - CORRECT ANSWER - All orders must be authenticated by the responsible
provider.
True - CORRECT ANSWER - American Osteopathic Association (AOA) requirements
state that a patient record must be maintained for each patient treated in the emergency
department.
Newborn record - CORRECT ANSWER - An APGAR score is documented in the:
False - CORRECT ANSWER - An admission note documented by the attending physician
can replace a dictated history and physical examination .
False - CORRECT ANSWER - An advance directive and an informed consent are
considered clinical data.
, Review of Systems (ROS) - CORRECT ANSWER - An inventory of body systems to
reveal subjective symptoms stated by the patient is called the __________.
state departments of health or offices of vital statistics - CORRECT ANSWER - Birth
certificate information is usually submitted to the ______ within 10 days of birth.
Labor and delivery record - CORRECT ANSWER - 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:
Differential diagnoses - CORRECT ANSWER - Dr. Cook records the following as part of
a history and physical examination: "Patient presents with abdominal pain of seven days'
duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out
appendicitis vs. obstruction of colon." The diagnoses recorded are:
Encounter form - CORRECT ANSWER - Dr. Health sees Jack in her office to monitor his
blood chemistry. She completes an examination and orders blood tests. Her medical assistant
completes the venipuncture. Charges for the services would be recorded on an:
Chief complaint - CORRECT ANSWER - Dr. Jones completes an admission history and
physical on Bob Lot, who states, "when I walk upstairs, I have difficulty breathing." This
statement is known as the patient's
Report of consultation - CORRECT ANSWER - 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. Hart, a cardiologist, to evaluate Mary's chest pain. Dr. Hart would
document his examination of the patient, pertinent findings, recommendations, and opinions on
the:
Forms committee - CORRECT ANSWER - 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:
