HIT 101 Chapter 4, Health Record Content and Documentation Exam Questions and Answers Fully Solved Latest Update

HIT 101 Chapter 4, Health Record Content and Documentation Exam Questions and Answers Fully Solved Latest Update The overall goal of documentation standards is: - Answers To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient A hospital that participates in the Medicare and Medicaid programs must follow: - Answers the conditions of participation When defining its legal health record, a healthcare provider organization must do which of the following? *access the legal environment *Determine what other healthcare provider organizations are doing *Decide if a legal health record is needed *Include only the paper components of the health record - Answers assess the legal environment Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists the patient's past medical, personal, and family history? - Answers medical history General documentation guidelines apply to: *only electronic health records *All categories of healthcare records *Only emergency health records *clinical observations - Answers All categories of healthcare record True of False: Health record entries should be documented at the time the services they describe are rendered. - Answers True True of False: Only individuals authorized by the organization's policies should be allowed to enter documentation in the health record. - Answers True True of False: Auto-authentication is the preferred method of authentication. - Answers False True or False: When an error is made, the erroneous information can be obliterated. - Answers False A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data? - Answers Administrative Data Patient history questionnaires, problem lists, diagnostic test results, and immunization records are commonly found in which type of record? *Ambulatory record *Emergency department record *Long-term care record *Rehabilitative care record - Answers Ambulatory Record What type of health records may contain family and caregiver input? - Answers Behavioral health record The ambulatory surgery record contains information most similar to which of the following? *physician's office records *emergency care records *hospital operative records