Week 4: Domain 3 Health Records
Quiz with correct answers
Based on the following documentation in an acute care record, where would you expect this
excerpt to appear?
Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub.
He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated
with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and
shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and
followed as an outpatient.
clinical laboratory report
admission note
discharge summary
physical exam - correct answer ✔✔discharge summary
Discharge summary is a document completed by the attending physician when the patient
leaves the hospital. The goal is to communicate thepatient's care plan to the post-hospital
provider. The excerpt clearly indicates an overall summary of the patient's course in the
hospital. Wronganswers: 1) Admission note is part of a medical record that documents the
patient's status at the time of admission including the reasons why thepatient is being admitted
for care. 2) Physical exam routine examination performed by the healthcare provider to assess
the patient's overallhealth status. 3) Clinical laboratory report are laboratory tests done on
specimens in order to determine the health of a patient.
,Ultimate responsibility for the quality and completion of entries in patient health records
belongs to the
HIM director.
chief of staff.
attending physician.
risk manager. - correct answer ✔✔attending physician
Although the nursing staff, hospital administration, and the health information management
director play a role in ensuring an accurate and complete record, the major responsibility lies
with the attending physician.
John, a 22-year-old male, told Dr. Paulson that he hit his head at work, hard. His buddy stated
that John had lost consciousness for about a minute. Dr. Paulson orders an MRI of the patient's
brain and an x-ray of his skull. Then, John mentioned that he hurt his shoulder when he fell, so
Dr. Paulson added an x-ray of the left shoulder. Radiologist's report confirms a brain concussion,
and shoulder image was negative. Dx: Brain concussion. Px: E/M, Brain MRI, X-ray Skull, X-ray
Shoulder.
Determine What critical information is missing?
Medical necessity for shoulder x-ray
John's buddy's name
Medical necessity for skull x-ray
,Length of time patient was unconscious - correct answer ✔✔Medical necessity for shoulder x-
ray
There is a diagnostic statement of the brain concussion to support the Evaluation and
Management (E/M), the MRI of the brain, and the skull x-ray. However, there is no
documentation of a diagnosis to provided medical necessity of the shoulder x-ray. Therefore,
medical necessity for shoulder x-ray is the critical information that is missing. John's buddy's
name and the length of time the patient was unconscious are not necessary in the
documentation.
Determine the primary focus of screen format design in a health record computer application
should be to ensure that
data fields can be randomly accessed.
the user is capturing essential data elements.
paper forms are easily converted to computer forms.
programmers develop standard screen formats for all hospitals. - correct answer ✔✔the user is
capturing essential data elements.
Both paper-based and computer-based records share similar design considerations. Among
these are the selection and sequencing of essential data items.
The utilization review coordinator reviews inpatient records at regular intervals to justify
necessity and appropriateness of care to warrant further hospitalization. Which of the following
utilization review activities is being performed?
, preadmission
continued stay review
admission review
retrospective review - correct answer ✔✔continued stay review
A continued stay review documents the necessity that each day of hospitalization is required,
and treatment is being provided at the appropriatelevel. The phrase "to warrant further
hospitalization" directly indicates the review is for continued stay. Wrong answers: 1) Admission
reviewdetermination of medical necessity as to whether hospitalizing is appropriate. 2) Pre-
admission review refers to approval by a case manager orthird-party payer representative for a
person to be admitted to a hospital prior to the admittance. 3) Retrospective review the review
processtake place after treatment is provided.
A set of standards that makes sharing clinical and administrative data possible between
healthcare entities by allowing different software packages to interface with one another is
known as
HL-7.
CDA.
CCD.
QRDA. - correct answer ✔✔HL-7.
Quiz with correct answers
Based on the following documentation in an acute care record, where would you expect this
excerpt to appear?
Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub.
He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated
with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and
shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and
followed as an outpatient.
clinical laboratory report
admission note
discharge summary
physical exam - correct answer ✔✔discharge summary
Discharge summary is a document completed by the attending physician when the patient
leaves the hospital. The goal is to communicate thepatient's care plan to the post-hospital
provider. The excerpt clearly indicates an overall summary of the patient's course in the
hospital. Wronganswers: 1) Admission note is part of a medical record that documents the
patient's status at the time of admission including the reasons why thepatient is being admitted
for care. 2) Physical exam routine examination performed by the healthcare provider to assess
the patient's overallhealth status. 3) Clinical laboratory report are laboratory tests done on
specimens in order to determine the health of a patient.
,Ultimate responsibility for the quality and completion of entries in patient health records
belongs to the
HIM director.
chief of staff.
attending physician.
risk manager. - correct answer ✔✔attending physician
Although the nursing staff, hospital administration, and the health information management
director play a role in ensuring an accurate and complete record, the major responsibility lies
with the attending physician.
John, a 22-year-old male, told Dr. Paulson that he hit his head at work, hard. His buddy stated
that John had lost consciousness for about a minute. Dr. Paulson orders an MRI of the patient's
brain and an x-ray of his skull. Then, John mentioned that he hurt his shoulder when he fell, so
Dr. Paulson added an x-ray of the left shoulder. Radiologist's report confirms a brain concussion,
and shoulder image was negative. Dx: Brain concussion. Px: E/M, Brain MRI, X-ray Skull, X-ray
Shoulder.
Determine What critical information is missing?
Medical necessity for shoulder x-ray
John's buddy's name
Medical necessity for skull x-ray
,Length of time patient was unconscious - correct answer ✔✔Medical necessity for shoulder x-
ray
There is a diagnostic statement of the brain concussion to support the Evaluation and
Management (E/M), the MRI of the brain, and the skull x-ray. However, there is no
documentation of a diagnosis to provided medical necessity of the shoulder x-ray. Therefore,
medical necessity for shoulder x-ray is the critical information that is missing. John's buddy's
name and the length of time the patient was unconscious are not necessary in the
documentation.
Determine the primary focus of screen format design in a health record computer application
should be to ensure that
data fields can be randomly accessed.
the user is capturing essential data elements.
paper forms are easily converted to computer forms.
programmers develop standard screen formats for all hospitals. - correct answer ✔✔the user is
capturing essential data elements.
Both paper-based and computer-based records share similar design considerations. Among
these are the selection and sequencing of essential data items.
The utilization review coordinator reviews inpatient records at regular intervals to justify
necessity and appropriateness of care to warrant further hospitalization. Which of the following
utilization review activities is being performed?
, preadmission
continued stay review
admission review
retrospective review - correct answer ✔✔continued stay review
A continued stay review documents the necessity that each day of hospitalization is required,
and treatment is being provided at the appropriatelevel. The phrase "to warrant further
hospitalization" directly indicates the review is for continued stay. Wrong answers: 1) Admission
reviewdetermination of medical necessity as to whether hospitalizing is appropriate. 2) Pre-
admission review refers to approval by a case manager orthird-party payer representative for a
person to be admitted to a hospital prior to the admittance. 3) Retrospective review the review
processtake place after treatment is provided.
A set of standards that makes sharing clinical and administrative data possible between
healthcare entities by allowing different software packages to interface with one another is
known as
HL-7.
CDA.
CCD.
QRDA. - correct answer ✔✔HL-7.
