HITT 1301 Exam 2-Questions 2025/2026 with 100%
Correct Solutions
Since the early _______, outpatient services have steadily increased due to cost savings
associated with providing health care on an ambulatory instead of an inpatient basis.
1980s
Authentication
which means an entry is signed by the author (e.g., provider)
Types of Authentication
*Written signatures
*Countersignatures
*Initials
*Fax signatures
*Electronic signatures or computer key signatures
*Signature stamps
Countersignature
form of authentication by an individual in addition to the signature by the original author of an
entry. The Federal Regulations/Interpretive Guidelines for Hospitals (482.24(c)(1)(i)) require
medical staff rules and regulations to identify types of documents nonphysicians may complete
as well as entries that require _____________ by a supervisory or attending medical staff
member.
Telephone Order (T.O)
,verbal order taken over the telephone by a qualified professional (e.g., registered nurse) from a
physician
Voice Order; Verbal Order (V.O)
is an order where the physician dictates an order in the presence of a responsible person. Is
documented in emergencies only.
Abbreviation List
medical staff-approved abbreviations, acronyms, and symbols (and their meanings) that can be
documented in patient records.
If record is illegible....
All entries in the patient record must be legible, and if an entry is illegible it should be rewritten
by its author. The rewritten entry should state "Clarified entry of (date)" and contain exactly the
same information as the original entry; it should be documented on the next available line in the
record (e.g., progress notes).
Accrediting and licensing agencies require the timely completion of documentation, such as
the Medicare Conditions of Participation (CoP) for hospitals that require a complete
physical examination to be performed no more than ___ days prior to admission or within
____ hours after admission.
30, 24
The Joint Commission requires patient records to be completed ____ days after the patient
is discharged, at which time they become delinquent records
30
, Records that remain incomplete 30 days after patient discharge (The Joint Commission
standard).
Delinquent Records
It is occasionally necessary to correct documentation in the patient record which is called
Amending the patient record
The only person authorized to correct an entry is ________
the author of the original entry
How to amend a patient record
**Draw a single line through the incorrect information, making sure that the original entry
remains legible
**Date, specify time, and sign the corrected entry
**Document a reason for the error in a location as close to the original documentation as
possible (e.g., "entry made in error" or "entry made in wrong chart")
**Enter the correct information as close to the original information as possible. If the length of
information to be newly entered prohibits this, enter the correct information in the next available
space in the record, and reference the original entry.
Re-dictation
Correct Solutions
Since the early _______, outpatient services have steadily increased due to cost savings
associated with providing health care on an ambulatory instead of an inpatient basis.
1980s
Authentication
which means an entry is signed by the author (e.g., provider)
Types of Authentication
*Written signatures
*Countersignatures
*Initials
*Fax signatures
*Electronic signatures or computer key signatures
*Signature stamps
Countersignature
form of authentication by an individual in addition to the signature by the original author of an
entry. The Federal Regulations/Interpretive Guidelines for Hospitals (482.24(c)(1)(i)) require
medical staff rules and regulations to identify types of documents nonphysicians may complete
as well as entries that require _____________ by a supervisory or attending medical staff
member.
Telephone Order (T.O)
,verbal order taken over the telephone by a qualified professional (e.g., registered nurse) from a
physician
Voice Order; Verbal Order (V.O)
is an order where the physician dictates an order in the presence of a responsible person. Is
documented in emergencies only.
Abbreviation List
medical staff-approved abbreviations, acronyms, and symbols (and their meanings) that can be
documented in patient records.
If record is illegible....
All entries in the patient record must be legible, and if an entry is illegible it should be rewritten
by its author. The rewritten entry should state "Clarified entry of (date)" and contain exactly the
same information as the original entry; it should be documented on the next available line in the
record (e.g., progress notes).
Accrediting and licensing agencies require the timely completion of documentation, such as
the Medicare Conditions of Participation (CoP) for hospitals that require a complete
physical examination to be performed no more than ___ days prior to admission or within
____ hours after admission.
30, 24
The Joint Commission requires patient records to be completed ____ days after the patient
is discharged, at which time they become delinquent records
30
, Records that remain incomplete 30 days after patient discharge (The Joint Commission
standard).
Delinquent Records
It is occasionally necessary to correct documentation in the patient record which is called
Amending the patient record
The only person authorized to correct an entry is ________
the author of the original entry
How to amend a patient record
**Draw a single line through the incorrect information, making sure that the original entry
remains legible
**Date, specify time, and sign the corrected entry
**Document a reason for the error in a location as close to the original documentation as
possible (e.g., "entry made in error" or "entry made in wrong chart")
**Enter the correct information as close to the original information as possible. If the length of
information to be newly entered prohibits this, enter the correct information in the next available
space in the record, and reference the original entry.
Re-dictation
