HIM Final Exam (Part 1) Questions And
Answers63
account number - ANSWERS -Nine-digit number assigned upon patient admission.
account number - ANSWERS -Patient receives a new _____ upon each admission to the facility.
care, treatment, services - ANSWERS -Joint Commission standards state that the patient record
needs to contain significant specific patient information related to _____, _____, and _____
provided.
clinical, case, demographic - ANSWERS -Patient records contain _______, ______, and ______
information.
medical record service - ANSWERS -CoP requires that each hospital establish a _________ and
that hospitals must maintain a _____ for all patients.
written, completed, filed, retained, accessible - ANSWERS -CoP requires that records must be
accurately ______, promptly _______, properly ______ and _____, and ________.
author identification, record maintenance, authentication, authenticated, dated - ANSWERS -For
security purposes, CoP requires that the hospital must use a system of __________ and
_________ that ensures the integrity of _______. All record entries be ________ and ______
promptly by appropriate person.
diagnosis, admission, hospitalization - ANSWERS -CoP requires that the hospital record must
contain information to justify _____, ________ and _______.
,progress, response, changes, follow through - ANSWERS -CoP requires that the record must
contain information that describes patient's ________ and ________ to medications and
services. It also must describe any _______ to the patients condition and _______ actions
taken.
5 years - ANSWERS -CoP requires records to be retained for at least _______.
coding, indexing - ANSWERS -CoP requires that hospital have a system of _______ and ______
to allow for timely retrieval.
confidentiality - ANSWERS -CoP requires that hospitals have procedure for ensuring _________
of patient information.
federal and state laws, court order, subpoena - ANSWERS -CoP states the records can only be
released by hospital in accordance with _________, ________, and ________.
patient record - ANSWERS -A valuable tool that documents the care and treatment of a patient.
patient identification - ANSWERS -Every report of the record must contain _________.
name, medical record number, date of birth - ANSWERS -Patient identifying information can
include: ______, ________, and _______.
name, medical record number - ANSWERS -Every page/screen must include the patient's
______ and ________.
alias - ANSWERS -Some patients insist on using an assumed name. This is called an ______.
,false - ANSWERS -True or False. Patients that use an assumed name will be reimbursed by their
insurance company.
attending, primary care, date of admission, visit - ANSWERS -It is common for health care
facilities to print the _______ or ______ physician's name and the _______ or ______ on each
form.
addressograph machine - ANSWERS -Imprints patient identification information on each report
and allows for forms to be imprinted prior to patient admission.
facility identification - ANSWERS -In addition to patient information, _______ must also be
included on each report in the record.
dated and timed - ANSWERS -For a record to be admissible in a court of law, all patient record
entries must be ______ and ______.
asap - ANSWERS -Providers must document entries ________ after care and treatment.
pre-dated, post-dated - ANSWERS -_______ and ________ entries are not allowed in the record.
actual - ANSWERS -When nurses summarize patient care at the end of a shift, documentation
should include ______ date and time the entry was made in the record.
facility name, mailing address, and telephone number - ANSWERS -Facility identifying
information should include ______, ______, and _______.
author - ANSWERS -Entries should be documented and signed by ______.
, communication - ANSWERS -The patient record must contain any _______ provided to patient's
family or physician.
completed - ANSWERS -All fields on preprinted forms should be ______.
amend - ANSWERS -If an original entry is incomplete, the provider should _______ the entry.
charting instructions - ANSWERS -If documentation is reported only when a specific behavior
occurs, then the provider must indicate appropriate _________.
consistent - ANSWERS -Entries should be _______ with documentation in the record.
explanation - ANSWERS -If documentation is contradictory, an ______ should be included.
skip, blanks - ANSWERS -Providers should not _______ lines or leave ______.
new form - ANSWERS -Do not generate a ______ until the previous form is filled.
remaining space - ANSWERS -If a new form is started, the provider should cross out any
___________ on the previous form.
falsified - ANSWERS -Blank space on the form raises the question that the record may be
_________.
objective, opinions - ANSWERS -Be _______ and state only facts about patient care and
treatment. Don't document ________.
Answers63
account number - ANSWERS -Nine-digit number assigned upon patient admission.
account number - ANSWERS -Patient receives a new _____ upon each admission to the facility.
care, treatment, services - ANSWERS -Joint Commission standards state that the patient record
needs to contain significant specific patient information related to _____, _____, and _____
provided.
clinical, case, demographic - ANSWERS -Patient records contain _______, ______, and ______
information.
medical record service - ANSWERS -CoP requires that each hospital establish a _________ and
that hospitals must maintain a _____ for all patients.
written, completed, filed, retained, accessible - ANSWERS -CoP requires that records must be
accurately ______, promptly _______, properly ______ and _____, and ________.
author identification, record maintenance, authentication, authenticated, dated - ANSWERS -For
security purposes, CoP requires that the hospital must use a system of __________ and
_________ that ensures the integrity of _______. All record entries be ________ and ______
promptly by appropriate person.
diagnosis, admission, hospitalization - ANSWERS -CoP requires that the hospital record must
contain information to justify _____, ________ and _______.
,progress, response, changes, follow through - ANSWERS -CoP requires that the record must
contain information that describes patient's ________ and ________ to medications and
services. It also must describe any _______ to the patients condition and _______ actions
taken.
5 years - ANSWERS -CoP requires records to be retained for at least _______.
coding, indexing - ANSWERS -CoP requires that hospital have a system of _______ and ______
to allow for timely retrieval.
confidentiality - ANSWERS -CoP requires that hospitals have procedure for ensuring _________
of patient information.
federal and state laws, court order, subpoena - ANSWERS -CoP states the records can only be
released by hospital in accordance with _________, ________, and ________.
patient record - ANSWERS -A valuable tool that documents the care and treatment of a patient.
patient identification - ANSWERS -Every report of the record must contain _________.
name, medical record number, date of birth - ANSWERS -Patient identifying information can
include: ______, ________, and _______.
name, medical record number - ANSWERS -Every page/screen must include the patient's
______ and ________.
alias - ANSWERS -Some patients insist on using an assumed name. This is called an ______.
,false - ANSWERS -True or False. Patients that use an assumed name will be reimbursed by their
insurance company.
attending, primary care, date of admission, visit - ANSWERS -It is common for health care
facilities to print the _______ or ______ physician's name and the _______ or ______ on each
form.
addressograph machine - ANSWERS -Imprints patient identification information on each report
and allows for forms to be imprinted prior to patient admission.
facility identification - ANSWERS -In addition to patient information, _______ must also be
included on each report in the record.
dated and timed - ANSWERS -For a record to be admissible in a court of law, all patient record
entries must be ______ and ______.
asap - ANSWERS -Providers must document entries ________ after care and treatment.
pre-dated, post-dated - ANSWERS -_______ and ________ entries are not allowed in the record.
actual - ANSWERS -When nurses summarize patient care at the end of a shift, documentation
should include ______ date and time the entry was made in the record.
facility name, mailing address, and telephone number - ANSWERS -Facility identifying
information should include ______, ______, and _______.
author - ANSWERS -Entries should be documented and signed by ______.
, communication - ANSWERS -The patient record must contain any _______ provided to patient's
family or physician.
completed - ANSWERS -All fields on preprinted forms should be ______.
amend - ANSWERS -If an original entry is incomplete, the provider should _______ the entry.
charting instructions - ANSWERS -If documentation is reported only when a specific behavior
occurs, then the provider must indicate appropriate _________.
consistent - ANSWERS -Entries should be _______ with documentation in the record.
explanation - ANSWERS -If documentation is contradictory, an ______ should be included.
skip, blanks - ANSWERS -Providers should not _______ lines or leave ______.
new form - ANSWERS -Do not generate a ______ until the previous form is filled.
remaining space - ANSWERS -If a new form is started, the provider should cross out any
___________ on the previous form.
falsified - ANSWERS -Blank space on the form raises the question that the record may be
_________.
objective, opinions - ANSWERS -Be _______ and state only facts about patient care and
treatment. Don't document ________.
