HIT 125 MIDTERM EXAM 2025/26 QUESTIONS WITH
100% CORRECT ANSWERS.
Which of the following is not usually a component of acute care patient
records? Answer - problem list
Which area of the record is used to ensure continuity of future patient care?
Answer - discharge summary
A nurse is responsible for which of the following types of acute care
documentation? Answer - medication record
Which of the following is an example of clinical data? Answer - admitting
diagnosis
The number of ligatures, sutures, packs, drains, and sponges used and
specimens removed would be found in the __________. Answer - operative
report
Which type of specialized record includes care provided prior to arrival at a
healthcare setting and times and means of arrival? Answer - emergency care
record
Documentation standards and guidelines are published by a variety of private
and public organizations, including the ________ Answer - All of the above
(* Joint Commission
*American Health Information Management Association
, *National Committee for Quality Assurance)
Which of the following is true of electronic-based medical records? Answer -
can be accessed by multiple end users simultaneously
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
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
What is the function of physician's orders? Answer - to document the
physician's instructions to other parties involved in providing care to a patient
Which of the following is an example of an advance directive? Answer - living
will
Most ambulatory care settings can earn accreditation from all but this
organization? Answer - CARF
In a medical history, which of the following is a detailed chronological
description of the development of the patient's illness? Answer - present
illness
Accreditation from the National Committee for Quality assurance focuses on
____________ Answer - Managed Care Organizations
100% CORRECT ANSWERS.
Which of the following is not usually a component of acute care patient
records? Answer - problem list
Which area of the record is used to ensure continuity of future patient care?
Answer - discharge summary
A nurse is responsible for which of the following types of acute care
documentation? Answer - medication record
Which of the following is an example of clinical data? Answer - admitting
diagnosis
The number of ligatures, sutures, packs, drains, and sponges used and
specimens removed would be found in the __________. Answer - operative
report
Which type of specialized record includes care provided prior to arrival at a
healthcare setting and times and means of arrival? Answer - emergency care
record
Documentation standards and guidelines are published by a variety of private
and public organizations, including the ________ Answer - All of the above
(* Joint Commission
*American Health Information Management Association
, *National Committee for Quality Assurance)
Which of the following is true of electronic-based medical records? Answer -
can be accessed by multiple end users simultaneously
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
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
What is the function of physician's orders? Answer - to document the
physician's instructions to other parties involved in providing care to a patient
Which of the following is an example of an advance directive? Answer - living
will
Most ambulatory care settings can earn accreditation from all but this
organization? Answer - CARF
In a medical history, which of the following is a detailed chronological
description of the development of the patient's illness? Answer - present
illness
Accreditation from the National Committee for Quality assurance focuses on
____________ Answer - Managed Care Organizations
