HIM 317 Final Exam Review Questions and Answers Already Passed
Both the Joint Commission and CMS expect this documentation to be placed in the hospital
patient's record before a surgical procedure is performed. - Answers history and physical
examination
Hospitals accredited by the Joint Commission or the AOA are also considered in compliance
with Medicare Conditions of Participation, an official designation called______ status. - Answers
deemed
A health record is arranged in chronological order with documentation from various sources
intermingled. This is an example of the ______format. - Answers integrated
What does "P" in "SOAP" stand for? - Answers Plan of treatment
Data exchange, or message format, standards support EHR interoperability. The structure or
format of data elements in a message is referred to as _______. - Answers syntax
You're asked to develop a new electronic health record screen view. Your first priority in
preparing a draft should be: - Answers The needs of the users
Which organization has created standards for EHR system functions? - Answers HL7
Also known as a clinical resume, this document provides a concise account of the patient's
illness, course of treatment, response and condition on exit from the hospital. The physician
principally responsible for the patient's care composes and signs it. - Answers Discharge
summary
Before a hospital is permitted to provide medical services in a particular state, the organization
must first go through what process? - Answers Licensure
A patient medical record is an example of a ____. - Answers Primary data source
What is the term used for the official business record created by or for the health care
organization? - Answers Legal health record
Before a physician will be permitted to provide patient services in a specific facility, or make
entries in a record, he/she must first go through which of the following processes? - Answers
Credentialing and privileging
What health record format is in use when documents are grouped together according to their
point of origin? - Answers Source-oriented
Which health record format is arranged n chronological order with documentation from various
sources? - Answers Integrated
What is the MOST important component of the health records? - Answers Clinical
Both the Joint Commission and CMS expect this documentation to be placed in the hospital
patient's record before a surgical procedure is performed. - Answers history and physical
examination
Hospitals accredited by the Joint Commission or the AOA are also considered in compliance
with Medicare Conditions of Participation, an official designation called______ status. - Answers
deemed
A health record is arranged in chronological order with documentation from various sources
intermingled. This is an example of the ______format. - Answers integrated
What does "P" in "SOAP" stand for? - Answers Plan of treatment
Data exchange, or message format, standards support EHR interoperability. The structure or
format of data elements in a message is referred to as _______. - Answers syntax
You're asked to develop a new electronic health record screen view. Your first priority in
preparing a draft should be: - Answers The needs of the users
Which organization has created standards for EHR system functions? - Answers HL7
Also known as a clinical resume, this document provides a concise account of the patient's
illness, course of treatment, response and condition on exit from the hospital. The physician
principally responsible for the patient's care composes and signs it. - Answers Discharge
summary
Before a hospital is permitted to provide medical services in a particular state, the organization
must first go through what process? - Answers Licensure
A patient medical record is an example of a ____. - Answers Primary data source
What is the term used for the official business record created by or for the health care
organization? - Answers Legal health record
Before a physician will be permitted to provide patient services in a specific facility, or make
entries in a record, he/she must first go through which of the following processes? - Answers
Credentialing and privileging
What health record format is in use when documents are grouped together according to their
point of origin? - Answers Source-oriented
Which health record format is arranged n chronological order with documentation from various
sources? - Answers Integrated
What is the MOST important component of the health records? - Answers Clinical
