HIT 102 Midterm 4 Exam Questions And
Answers 100% Correct
Problem oriented health record - ANSWER A way of organizing information in a health
record in which clinical problems are defined and documented individually.
Source oriented health record - ANSWER A format of health record organization in
which information is arranged according to the patient care department.
Integrated health record - ANSWER A system of health record organization in which all
of the paper forms are arranged in strict chronological order.
H&P (History and Physical) - ANSWER Must be on the medical record within 24 hours of
admission.
Operative Report - ANSWER Must be on the medical record immediately after the
surgery.
Pre-anesthesia orders - ANSWER Evaluation, must be performed by and an individual
qualified to administer anesthesia within 48 hours prior to surgery.
As a concurrent record reviewer for an acute care facility, you have asked Dr Schnering
to provide an updated history and physical for one of his recent inpatient admissions.
Dr. Schnering pages through the medical record to a copy of an H&P performed in his
office a week before admission. You tell Dr Schnering: - ANSWER the H&P copy is
acceptable as long as he documents any interval changes since the H&P was originally
written
In an acute care hospital, a complete history and physical does not have to be dictated
for a new admission when: - ANSWER a legible copy of a H&P performed in the
attending physician's office within the week preceding the inpatient admission is on the
hospital record
, Which of the following includes names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed? - ANSWER operative
report
If an inpatient's stay is not complicated and lasts less than 48 hours, or involves an
uncomplicated delivery or normal newborn, a discharge note in place of a full discharge
summary is often acceptable. - ANSWER True
Which of the following groups is the primary accreditation organization for facilities that
treat individuals who have functional disabilities? - ANSWER Commission on
Accreditation of Rehabilitation Facilities (CARF)
When correcting erroneous information in a paper health record, which of the following
is appropriate? - ANSWER A.Add the reason for the change.**********
B. Print "addendum" above the entry
C. Backdate to the date that the addendum covers
D.Use a black pen to obliterate the entry
What is the function of a consultation report? - ANSWER Documents opinions about the
patient's condition from the perspective of a physician not previously involved in the
patient's care
Which of the following represents documentation of the patient's current and past
health status? - ANSWER Medical history
Which of the following contains the physician's findings based on an examination of the
patient? - ANSWER Physical exam
Which of the following is usually a component of acute care patient records? - ANSWER
Progress notes
Answers 100% Correct
Problem oriented health record - ANSWER A way of organizing information in a health
record in which clinical problems are defined and documented individually.
Source oriented health record - ANSWER A format of health record organization in
which information is arranged according to the patient care department.
Integrated health record - ANSWER A system of health record organization in which all
of the paper forms are arranged in strict chronological order.
H&P (History and Physical) - ANSWER Must be on the medical record within 24 hours of
admission.
Operative Report - ANSWER Must be on the medical record immediately after the
surgery.
Pre-anesthesia orders - ANSWER Evaluation, must be performed by and an individual
qualified to administer anesthesia within 48 hours prior to surgery.
As a concurrent record reviewer for an acute care facility, you have asked Dr Schnering
to provide an updated history and physical for one of his recent inpatient admissions.
Dr. Schnering pages through the medical record to a copy of an H&P performed in his
office a week before admission. You tell Dr Schnering: - ANSWER the H&P copy is
acceptable as long as he documents any interval changes since the H&P was originally
written
In an acute care hospital, a complete history and physical does not have to be dictated
for a new admission when: - ANSWER a legible copy of a H&P performed in the
attending physician's office within the week preceding the inpatient admission is on the
hospital record
, Which of the following includes names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed? - ANSWER operative
report
If an inpatient's stay is not complicated and lasts less than 48 hours, or involves an
uncomplicated delivery or normal newborn, a discharge note in place of a full discharge
summary is often acceptable. - ANSWER True
Which of the following groups is the primary accreditation organization for facilities that
treat individuals who have functional disabilities? - ANSWER Commission on
Accreditation of Rehabilitation Facilities (CARF)
When correcting erroneous information in a paper health record, which of the following
is appropriate? - ANSWER A.Add the reason for the change.**********
B. Print "addendum" above the entry
C. Backdate to the date that the addendum covers
D.Use a black pen to obliterate the entry
What is the function of a consultation report? - ANSWER Documents opinions about the
patient's condition from the perspective of a physician not previously involved in the
patient's care
Which of the following represents documentation of the patient's current and past
health status? - ANSWER Medical history
Which of the following contains the physician's findings based on an examination of the
patient? - ANSWER Physical exam
Which of the following is usually a component of acute care patient records? - ANSWER
Progress notes
