HIT 125 Exam with 100% Correct
Answers
Which best describes the most important function of the health record? - ANSWER-
Storing patient care documentation
Clinical professionals who provide direct patient care are __________ users of the
health record? - ANSWER-primary
Which element is typically found in the paper health record? - ANSWER-Patient
identification
The patient registration department assists the HIM department in what way? -
ANSWER-Assigning the health record number
The master patient index contains ____________ - ANSWER-basic demographic
information about the patient
Which filing system is being used if these numbers represent the health record
numbers:
36-45-99
37-45-99
38-45-99 - ANSWER-Terminal digit
The release of information function requires the HIM professional to: - ANSWER-
Disclose patient identifiable information to a third party
Which system is best suited for a small healthcare facility such as a one-physician
practice? - ANSWER-Alphabetic filing system
In which system does an individual receive a unique numerical identifier at the time of
first encounter and maintain that identifier for all subsequent encounters? - ANSWER-
Unit numbering system
Delinquent record - ANSWER-A record not completed within the time frame specified in
the medical staff rules and regulations
Which index is key to locating a health record? - ANSWER-Master patient index
Why should copy and paste function NOT be used in the electronic health record? -
ANSWER-The content may contain outdated information
, Which is a secondary purpose of the health record? - ANSWER-Support for research
A health record with deficiencies that is not complete within the timeframe specified in
the medical staff rules and regulations is called a ________ record. - ANSWER-
Delinquent
Term used for health record moved to an inactive file area because the patient has not
been at the healthcare facility for a predefined period of time - ANSWER-Purged
Which represents documentation of the patient's current and past health status? -
ANSWER-Medical history
Which contains the physician's findings based on an examination of the patient? -
ANSWER-Physical exam
Which is a usual component of acute care patient records? - ANSWER-Progress notes
The ambulatory surgery record contains information most similar to which records? -
ANSWER-Hospital operative records
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? - ANSWER-Emergency care
Patient account information includes: - ANSWER-Insurance
What is an example of a long-term care setting? - ANSWER-Assisted living facility
Which specialized type of progress note provides healthcare professionals impressions
of patient problems with detailed treatment action steps? - ANSWER-Care plan
In what part of the health record would the social and personal history be found? -
ANSWER-Medical history
The term ambulatory is the same as the term outpatient. - ANSWER-True
Nursing documentation should only be subjective. - ANSWER-False
What creates a chronological report of the patient's condition and response to treatment
during a hospital stay? - ANSWER-Progress notes
Which health record format is most commonly used by healthcare settings as they
transition to electronic records? - ANSWER-Hybrid records
Answers
Which best describes the most important function of the health record? - ANSWER-
Storing patient care documentation
Clinical professionals who provide direct patient care are __________ users of the
health record? - ANSWER-primary
Which element is typically found in the paper health record? - ANSWER-Patient
identification
The patient registration department assists the HIM department in what way? -
ANSWER-Assigning the health record number
The master patient index contains ____________ - ANSWER-basic demographic
information about the patient
Which filing system is being used if these numbers represent the health record
numbers:
36-45-99
37-45-99
38-45-99 - ANSWER-Terminal digit
The release of information function requires the HIM professional to: - ANSWER-
Disclose patient identifiable information to a third party
Which system is best suited for a small healthcare facility such as a one-physician
practice? - ANSWER-Alphabetic filing system
In which system does an individual receive a unique numerical identifier at the time of
first encounter and maintain that identifier for all subsequent encounters? - ANSWER-
Unit numbering system
Delinquent record - ANSWER-A record not completed within the time frame specified in
the medical staff rules and regulations
Which index is key to locating a health record? - ANSWER-Master patient index
Why should copy and paste function NOT be used in the electronic health record? -
ANSWER-The content may contain outdated information
, Which is a secondary purpose of the health record? - ANSWER-Support for research
A health record with deficiencies that is not complete within the timeframe specified in
the medical staff rules and regulations is called a ________ record. - ANSWER-
Delinquent
Term used for health record moved to an inactive file area because the patient has not
been at the healthcare facility for a predefined period of time - ANSWER-Purged
Which represents documentation of the patient's current and past health status? -
ANSWER-Medical history
Which contains the physician's findings based on an examination of the patient? -
ANSWER-Physical exam
Which is a usual component of acute care patient records? - ANSWER-Progress notes
The ambulatory surgery record contains information most similar to which records? -
ANSWER-Hospital operative records
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? - ANSWER-Emergency care
Patient account information includes: - ANSWER-Insurance
What is an example of a long-term care setting? - ANSWER-Assisted living facility
Which specialized type of progress note provides healthcare professionals impressions
of patient problems with detailed treatment action steps? - ANSWER-Care plan
In what part of the health record would the social and personal history be found? -
ANSWER-Medical history
The term ambulatory is the same as the term outpatient. - ANSWER-True
Nursing documentation should only be subjective. - ANSWER-False
What creates a chronological report of the patient's condition and response to treatment
during a hospital stay? - ANSWER-Progress notes
Which health record format is most commonly used by healthcare settings as they
transition to electronic records? - ANSWER-Hybrid records
