HIM 1000 - Chapter 4 Questions AND Correct Answers
"Acute allergic reaction" would be documented in which part of a
SOAP note? - ✔✔Assessment
1. Which of the following is not an example of a long-term care
setting?
A) Community mental health centers
B) Nursing homes
C) Subacute care organizations
D) Assisted living facilities - ✔✔A) Community mental health centers
10. Documentation of aides who assist a patient with activities of
daily living, bathing, laundry, and cleaning would be found in which
type of specialty record?
A) Home health
B) Rehabilitative care
C) End-stage renal disease
D) Behavioral health, - ✔✔A) Home health
11. A nurse is responsible for which of the following types of acute
care documentation?
A) Operative report
B) Radiology report
,C) Therapy assessment
D) Medication record - ✔✔D) Medication record
12. Which accrediting organization has instituted unannounced
surveys and requires submission of annual performance reviews?
A) American Osteopathic Association
B) Accreditation Association for Ambulatory Healthcare
C) Commission on Accreditation of Rehabilitation Facilities
D) Joint Commission - ✔✔D) Joint Commission
13. Which type of specialized record includes care provided prior to
arrival at a healthcare setting and times and means of arrival?
A) Ambulatory surgery record
B) Emergency care record
C) Pediatric record
D) Ambulatory care record - ✔✔B) Emergency care record
14. Which of the following is an example of an advance directive?
A) Authorization to disclose information
B) Patient's bill of rights
C) Living will
D) Notice of privacy practices - ✔✔C) Living will
,15. The attending physician is responsible for which of the following
types of acute- care documentation?
A) Discharge summary
B) Pathology report
C) Consultation report
D) Laboratory report - ✔✔A) Discharge summary
16. "The patient indicates that she is dizzy nauseous, and feels her
throat tightening." This entry would be recorded in which section of a
SOAP note?
A) Plan
B) Assessment
C) Subjective
D) Objective, - ✔✔C) Subjective
17. In a medical history which of the following is a detailed
chronological description of the development of the patient's illness?
A) Review of systems
B) Present illness
C) Past medical history
D) Chief complaint, - ✔✔B) Present illness
, 18. An RAI/MDS and care plan are found in records of patients in:
A) Home healthcare
B) Long-term care
C) Behavioral healthcare
D) Rehabilitative care - ✔✔B) Long-term care
2. The number of ligatures sutures, packs, drains, and sponges used
and specimens removed would be found in the:
A) Progress notes
B) Operative report
C) Recovery room report
D) Anesthesia report, - ✔✔B) Operative report
20. What is the general name for Medicare standards impacting
healthcare organizations?
A) Conditions of Participation
B) Terms of Accreditation
C) Regulations for Licensure
D) Requirements for Service - ✔✔A) Conditions of Participation
21. Which of the following is not usually a component of acute care
patient records?
A) Progress notes
"Acute allergic reaction" would be documented in which part of a
SOAP note? - ✔✔Assessment
1. Which of the following is not an example of a long-term care
setting?
A) Community mental health centers
B) Nursing homes
C) Subacute care organizations
D) Assisted living facilities - ✔✔A) Community mental health centers
10. Documentation of aides who assist a patient with activities of
daily living, bathing, laundry, and cleaning would be found in which
type of specialty record?
A) Home health
B) Rehabilitative care
C) End-stage renal disease
D) Behavioral health, - ✔✔A) Home health
11. A nurse is responsible for which of the following types of acute
care documentation?
A) Operative report
B) Radiology report
,C) Therapy assessment
D) Medication record - ✔✔D) Medication record
12. Which accrediting organization has instituted unannounced
surveys and requires submission of annual performance reviews?
A) American Osteopathic Association
B) Accreditation Association for Ambulatory Healthcare
C) Commission on Accreditation of Rehabilitation Facilities
D) Joint Commission - ✔✔D) Joint Commission
13. Which type of specialized record includes care provided prior to
arrival at a healthcare setting and times and means of arrival?
A) Ambulatory surgery record
B) Emergency care record
C) Pediatric record
D) Ambulatory care record - ✔✔B) Emergency care record
14. Which of the following is an example of an advance directive?
A) Authorization to disclose information
B) Patient's bill of rights
C) Living will
D) Notice of privacy practices - ✔✔C) Living will
,15. The attending physician is responsible for which of the following
types of acute- care documentation?
A) Discharge summary
B) Pathology report
C) Consultation report
D) Laboratory report - ✔✔A) Discharge summary
16. "The patient indicates that she is dizzy nauseous, and feels her
throat tightening." This entry would be recorded in which section of a
SOAP note?
A) Plan
B) Assessment
C) Subjective
D) Objective, - ✔✔C) Subjective
17. In a medical history which of the following is a detailed
chronological description of the development of the patient's illness?
A) Review of systems
B) Present illness
C) Past medical history
D) Chief complaint, - ✔✔B) Present illness
, 18. An RAI/MDS and care plan are found in records of patients in:
A) Home healthcare
B) Long-term care
C) Behavioral healthcare
D) Rehabilitative care - ✔✔B) Long-term care
2. The number of ligatures sutures, packs, drains, and sponges used
and specimens removed would be found in the:
A) Progress notes
B) Operative report
C) Recovery room report
D) Anesthesia report, - ✔✔B) Operative report
20. What is the general name for Medicare standards impacting
healthcare organizations?
A) Conditions of Participation
B) Terms of Accreditation
C) Regulations for Licensure
D) Requirements for Service - ✔✔A) Conditions of Participation
21. Which of the following is not usually a component of acute care
patient records?
A) Progress notes
