HRSC 206 Outcome 1 Health
Information Components Exam
Study Set
What is a health record? - Answer documentation relating to a healthcare client
Purpose of a health record? - Answer continuity of care
What is an eChart? - Answer electronic chart
What is a pChart? - Answer paper chart
What is Netcare? - Answer Alberta's EHR
What is a custodian? - Answer person or organization who has the responsibility for the
safekeeping and controlling personal health information.
What is a record? - Answer single document or collection of documents
What does a record document? - Answer presenting problem, history and diagnosis,
observations, assessments, outcome and plan for recovery
Who creates the health record? - Answer healthcare providers
When is the record created? - Answer occurs when the patient first seeks care
Where is the record created? - Answer at the location where the patient receives care
Who maintains the record in a hospital? - Answer health records department
Who maintains the record in a clinic setting? - Answer physician
Medical charts must be kept..? - Answer neat, accurate and complete
SOAP - Answer subjective, objective, assessment, plan
Patient flow - Answer moving patients through their healthcare experience
What is bed control? - Answer AHS term for patient flow
Four basic admission types - Answer Elective, emergency, obstetrical and outpatient
DOB rule for AHS registration - Answer YYYYMMDD
4 steps in the registration process - Answer 1. Positively identify the patient
2. Perform search
, 3. Verify demographics
4. Register
Define standard - Answer policy
Rule - Answer procedure
Best practice - Answer how the procedure is carried out
What is included in the demographic data rules? - Answer Name
Gender
DOB
DOD
Address
Phone number
Identifiers
Information required for admitting a newborn - Answer Baby's last name
Gender
Date and time of delivery
Type of delivery
Weight
Mother's full name
Mother's room and bed number
Name of baby's doctor
Elective admission type - Answer planned
Emergency admission type - Answer admitted from ER
Obstetrical admission type - Answer admitted once patient is in established, suspicious
or ineffective labour
Outpatient admission type - Answer no overnight stay
Information Components Exam
Study Set
What is a health record? - Answer documentation relating to a healthcare client
Purpose of a health record? - Answer continuity of care
What is an eChart? - Answer electronic chart
What is a pChart? - Answer paper chart
What is Netcare? - Answer Alberta's EHR
What is a custodian? - Answer person or organization who has the responsibility for the
safekeeping and controlling personal health information.
What is a record? - Answer single document or collection of documents
What does a record document? - Answer presenting problem, history and diagnosis,
observations, assessments, outcome and plan for recovery
Who creates the health record? - Answer healthcare providers
When is the record created? - Answer occurs when the patient first seeks care
Where is the record created? - Answer at the location where the patient receives care
Who maintains the record in a hospital? - Answer health records department
Who maintains the record in a clinic setting? - Answer physician
Medical charts must be kept..? - Answer neat, accurate and complete
SOAP - Answer subjective, objective, assessment, plan
Patient flow - Answer moving patients through their healthcare experience
What is bed control? - Answer AHS term for patient flow
Four basic admission types - Answer Elective, emergency, obstetrical and outpatient
DOB rule for AHS registration - Answer YYYYMMDD
4 steps in the registration process - Answer 1. Positively identify the patient
2. Perform search
, 3. Verify demographics
4. Register
Define standard - Answer policy
Rule - Answer procedure
Best practice - Answer how the procedure is carried out
What is included in the demographic data rules? - Answer Name
Gender
DOB
DOD
Address
Phone number
Identifiers
Information required for admitting a newborn - Answer Baby's last name
Gender
Date and time of delivery
Type of delivery
Weight
Mother's full name
Mother's room and bed number
Name of baby's doctor
Elective admission type - Answer planned
Emergency admission type - Answer admitted from ER
Obstetrical admission type - Answer admitted once patient is in established, suspicious
or ineffective labour
Outpatient admission type - Answer no overnight stay
