HIM 1000 - Chapter 4 Exam Questions And Answers
100% Correct A+ Rated
Which 2 major types of data are contained in the health record? - ANSWER
Administrative & clinical
Which of the following terms refers to state or county regulations that healthcare
facilities must meet to be permitted to provide care? - ANSWER Licensure
Which of the following would NOT be found in a medical history? - ANSWER Vital signs
An attending physician requests the advice of a second physician who then reviews the
health record & examines the patient. The second physician records impressions in
what type of report? - ANSWER Consultation
Which specialized type of progress note provides healthcare professionals impressions
of patient problems with detailed treatment action steps? - ANSWER Care plan
Written or spoken permission to proceed with care is calssified as? - ANSWER
Expressed consent
Which of the following reports provides information on tissue remove during a
procedure? - ANSWER Pathology report
Sleeping patterns, head & chest measurements, feeding & elimination status, weight,
and Apgar scores are recorded in which of following records? - ANSWER newborn
Which of the following is not considered patient demographic information? - ANSWER
Admitting diagnosis
,Which of the following administrative documents names the patients choice of legal
representative for healthcare purposes? - ANSWER Advance directive
Which type of health record contains information about care provided prior to arrival at
a healthcare setting & documentation of care provided to stabilize the patient? -
ANSWER Emergency care
Patient history questionnaires, problem lists, diagnostic test results, & immunization
records are commonly found in which type of record? - ANSWER Ambulatory care
The ambulatory surgery record contains information most similar to? - ANSWER
Hospital operative records
Which standardized tool is used to assess Medicare-certified rehab facilities? - ANSWER
Patietn assessment instrument (PAI)
Interdisciplinary care plan are an important part of which type of health record? -
ANSWER Hospice care
Portions of a treatment record may be maintained in a patients home in which 2 types of
settings? - ANSWER Home health & end-stage renal disease
A patients legal status, complaints of others regarding the patient, & reports of
restraints or seclusion would be found most frequently in which type of health record? -
ANSWER Behavioral health
Paper records may require thinning in which 2 settings? - ANSWER Long-term care &
correctional services
A growth & development record may be found in what type of record? - ANSWER
Pediatric
, The document that indicates current & past medical conditons is? - ANSWER Problem
list
Which of the following is an accrediting organization? - ANSWER DNV
An accrediting organizaiton is awarded deemed status by Medicare. This means that
facilities receiving accreditaiton under its guidelines do not need to? - ANSWER
Undergo Medicare certification surveys
Which group focuses on accreditation of managed care & preferred provider
organizations? - ANSWER National Committee for Quality Assurance
Which of the following regulations would most likely contain information on who is
authorized to enter documentation in a patients record? - ANSWER Facility rules &
regulations
Which of the following groups has instituted a health record-prohibited abbreviation
lsit? - ANSWER Joint commission on Accreditation of healthcare organizations
Which tupe of health record includes both paper & computerized components? -
ANSWER Hybrid
Which of the following is a disadvantage of an EHR over a paper-based record? -
ANSWER Requires privacy & security measures
In an integrated health record, documentation by health professionals is organized? -
ANSWER Intermized in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this
information be recorded? - ANSWER Subjective
100% Correct A+ Rated
Which 2 major types of data are contained in the health record? - ANSWER
Administrative & clinical
Which of the following terms refers to state or county regulations that healthcare
facilities must meet to be permitted to provide care? - ANSWER Licensure
Which of the following would NOT be found in a medical history? - ANSWER Vital signs
An attending physician requests the advice of a second physician who then reviews the
health record & examines the patient. The second physician records impressions in
what type of report? - ANSWER Consultation
Which specialized type of progress note provides healthcare professionals impressions
of patient problems with detailed treatment action steps? - ANSWER Care plan
Written or spoken permission to proceed with care is calssified as? - ANSWER
Expressed consent
Which of the following reports provides information on tissue remove during a
procedure? - ANSWER Pathology report
Sleeping patterns, head & chest measurements, feeding & elimination status, weight,
and Apgar scores are recorded in which of following records? - ANSWER newborn
Which of the following is not considered patient demographic information? - ANSWER
Admitting diagnosis
,Which of the following administrative documents names the patients choice of legal
representative for healthcare purposes? - ANSWER Advance directive
Which type of health record contains information about care provided prior to arrival at
a healthcare setting & documentation of care provided to stabilize the patient? -
ANSWER Emergency care
Patient history questionnaires, problem lists, diagnostic test results, & immunization
records are commonly found in which type of record? - ANSWER Ambulatory care
The ambulatory surgery record contains information most similar to? - ANSWER
Hospital operative records
Which standardized tool is used to assess Medicare-certified rehab facilities? - ANSWER
Patietn assessment instrument (PAI)
Interdisciplinary care plan are an important part of which type of health record? -
ANSWER Hospice care
Portions of a treatment record may be maintained in a patients home in which 2 types of
settings? - ANSWER Home health & end-stage renal disease
A patients legal status, complaints of others regarding the patient, & reports of
restraints or seclusion would be found most frequently in which type of health record? -
ANSWER Behavioral health
Paper records may require thinning in which 2 settings? - ANSWER Long-term care &
correctional services
A growth & development record may be found in what type of record? - ANSWER
Pediatric
, The document that indicates current & past medical conditons is? - ANSWER Problem
list
Which of the following is an accrediting organization? - ANSWER DNV
An accrediting organizaiton is awarded deemed status by Medicare. This means that
facilities receiving accreditaiton under its guidelines do not need to? - ANSWER
Undergo Medicare certification surveys
Which group focuses on accreditation of managed care & preferred provider
organizations? - ANSWER National Committee for Quality Assurance
Which of the following regulations would most likely contain information on who is
authorized to enter documentation in a patients record? - ANSWER Facility rules &
regulations
Which of the following groups has instituted a health record-prohibited abbreviation
lsit? - ANSWER Joint commission on Accreditation of healthcare organizations
Which tupe of health record includes both paper & computerized components? -
ANSWER Hybrid
Which of the following is a disadvantage of an EHR over a paper-based record? -
ANSWER Requires privacy & security measures
In an integrated health record, documentation by health professionals is organized? -
ANSWER Intermized in date sequence
The patient indicates that her pain is worse. In which part of a SOAP note would this
information be recorded? - ANSWER Subjective
