HIT 102 Midterm 4 Exam with Questions
and Correct Answers 2025
Problem oriented health record - CORRECT ANSWERSA way of organizing information in
a health record in which clinical problems are defined and documented individually.
Source oriented health record - CORRECT ANSWERS A format of health record
organization in which information is arranged according to the patient care department.
Integrated health record - CORRECT ANSWERSA system of health record organization in
which all of the paper forms are arranged in strict chronological order.
H&P (History and Physical) - CORRECT ANSWERSMust be on the medical record within
24 hours of admission.
Operative Report - CORRECT ANSWERSMust be on the medical record immediately
after the surgery.
Pre-anesthesia orders - CORRECT ANSWERSEvaluation, must be performed by and an
individual qualified to administer anesthesia within 48 hours prior to surgery.
As a concurrent record reviewer for an acute care facility, you have asked Dr Schnering to
provide an updated history and physical for one of his recent inpatient admissions. Dr.
Schnering pages through the medical record to a copy of an H&P performed in his office a
week before admission. You tell Dr Schnering: - CORRECT ANSWERSthe H&P copy is
acceptable as long as he documents any interval changes since the H&P was originally
written
In an acute care hospital, a complete history and physical does not have to be dictated for a
new admission when: - CORRECT ANSWERSa legible copy of a H&P performed in the
attending physician's office within the week preceding the inpatient admission is on the
hospital record
Which of the following includes names of the surgeon and assistants, date, duration, and
description of the procedure and any specimens removed? - CORRECT
ANSWERSoperative report
, If an inpatient's stay is not complicated and lasts less than 48 hours, or involves an
uncomplicated delivery or normal newborn, a discharge note in place of a full discharge
summary is often acceptable. - CORRECT ANSWERSTrue
Which of the following groups is the primary accreditation organization for facilities that
treat individuals who have functional disabilities? - CORRECT ANSWERSCommission on
Accreditation of Rehabilitation Facilities (CARF)
When correcting erroneous information in a paper health record, which of the following is
appropriate? - CORRECT ANSWERSA.Add the reason for the change.**********
B. Print "addendum" above the entry
C. Backdate to the date that the addendum covers
D.Use a black pen to obliterate the entry
What is the function of a consultation report? - CORRECT ANSWERSDocuments opinions
about the patient's condition from the perspective of a physician not previously involved in
the patient's care
Which of the following represents documentation of the patient's current and past health
status? - CORRECT ANSWERSMedical history
Which of the following contains the physician's findings based on an examination of the
patient? - CORRECT ANSWERSPhysical exam
Which of the following is usually a component of acute care patient records? - CORRECT
ANSWERSProgress notes
Which type of health record contains information about the means by which the patient
arrived at the healthcare setting and documentation of care provided to stabilize the
patient? - CORRECT ANSWERSEmergency care
Patient Account Information includes: - CORRECT ANSWERSA.Patient gender
B. Next of kin
C. Race
D. Insurance *********
True or false? The term ambulatory is the same as the term outpatient. - CORRECT
ANSWERSTrue
True or false? An increase of healthcare-related identity theft has had no influence on a
healthcare provider organization's decision not to collect Social Security Numbers from
patients. - CORRECT ANSWERSFalse
Which type of standard is required of hospitals by states prior to providing any healthcare?
- CORRECT ANSWERSLicensure
and Correct Answers 2025
Problem oriented health record - CORRECT ANSWERSA way of organizing information in
a health record in which clinical problems are defined and documented individually.
Source oriented health record - CORRECT ANSWERS A format of health record
organization in which information is arranged according to the patient care department.
Integrated health record - CORRECT ANSWERSA system of health record organization in
which all of the paper forms are arranged in strict chronological order.
H&P (History and Physical) - CORRECT ANSWERSMust be on the medical record within
24 hours of admission.
Operative Report - CORRECT ANSWERSMust be on the medical record immediately
after the surgery.
Pre-anesthesia orders - CORRECT ANSWERSEvaluation, must be performed by and an
individual qualified to administer anesthesia within 48 hours prior to surgery.
As a concurrent record reviewer for an acute care facility, you have asked Dr Schnering to
provide an updated history and physical for one of his recent inpatient admissions. Dr.
Schnering pages through the medical record to a copy of an H&P performed in his office a
week before admission. You tell Dr Schnering: - CORRECT ANSWERSthe H&P copy is
acceptable as long as he documents any interval changes since the H&P was originally
written
In an acute care hospital, a complete history and physical does not have to be dictated for a
new admission when: - CORRECT ANSWERSa legible copy of a H&P performed in the
attending physician's office within the week preceding the inpatient admission is on the
hospital record
Which of the following includes names of the surgeon and assistants, date, duration, and
description of the procedure and any specimens removed? - CORRECT
ANSWERSoperative report
, If an inpatient's stay is not complicated and lasts less than 48 hours, or involves an
uncomplicated delivery or normal newborn, a discharge note in place of a full discharge
summary is often acceptable. - CORRECT ANSWERSTrue
Which of the following groups is the primary accreditation organization for facilities that
treat individuals who have functional disabilities? - CORRECT ANSWERSCommission on
Accreditation of Rehabilitation Facilities (CARF)
When correcting erroneous information in a paper health record, which of the following is
appropriate? - CORRECT ANSWERSA.Add the reason for the change.**********
B. Print "addendum" above the entry
C. Backdate to the date that the addendum covers
D.Use a black pen to obliterate the entry
What is the function of a consultation report? - CORRECT ANSWERSDocuments opinions
about the patient's condition from the perspective of a physician not previously involved in
the patient's care
Which of the following represents documentation of the patient's current and past health
status? - CORRECT ANSWERSMedical history
Which of the following contains the physician's findings based on an examination of the
patient? - CORRECT ANSWERSPhysical exam
Which of the following is usually a component of acute care patient records? - CORRECT
ANSWERSProgress notes
Which type of health record contains information about the means by which the patient
arrived at the healthcare setting and documentation of care provided to stabilize the
patient? - CORRECT ANSWERSEmergency care
Patient Account Information includes: - CORRECT ANSWERSA.Patient gender
B. Next of kin
C. Race
D. Insurance *********
True or false? The term ambulatory is the same as the term outpatient. - CORRECT
ANSWERSTrue
True or false? An increase of healthcare-related identity theft has had no influence on a
healthcare provider organization's decision not to collect Social Security Numbers from
patients. - CORRECT ANSWERSFalse
Which type of standard is required of hospitals by states prior to providing any healthcare?
- CORRECT ANSWERSLicensure
