HIT 125 Midterm Exam Questions and Answers Latest Update 2025-2026
Which of the following is not usually a component of acute care patient records? - Answers
problem list
Which area of the record is used to ensure continuity of future patient care? - Answers
discharge summary
A nurse is responsible for which of the following types of acute care documentation? - Answers
medication record
Which of the following is an example of clinical data? - Answers admitting diagnosis
The number of ligatures, sutures, packs, drains, and sponges used and specimens removed
would be found in the __________. - Answers operative report
Which type of specialized record includes care provided prior to arrival at a healthcare setting
and times and means of arrival? - Answers emergency care record
Documentation standards and guidelines are published by a variety of private and public
organizations, including the ________ - Answers 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? - Answers can be accessed
by multiple end users simultaneously
Which of the following represents documentation of the patient's current and past health status?
- Answers medical history
Which of the following contains the physician's findings based on an examination of the patient?
- Answers physical exam
What is the function of a consultation report? - Answers 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? - Answers 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? - Answers living will
Most ambulatory care settings can earn accreditation from all but this organization? - Answers
CARF
Which of the following is not usually a component of acute care patient records? - Answers
problem list
Which area of the record is used to ensure continuity of future patient care? - Answers
discharge summary
A nurse is responsible for which of the following types of acute care documentation? - Answers
medication record
Which of the following is an example of clinical data? - Answers admitting diagnosis
The number of ligatures, sutures, packs, drains, and sponges used and specimens removed
would be found in the __________. - Answers operative report
Which type of specialized record includes care provided prior to arrival at a healthcare setting
and times and means of arrival? - Answers emergency care record
Documentation standards and guidelines are published by a variety of private and public
organizations, including the ________ - Answers 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? - Answers can be accessed
by multiple end users simultaneously
Which of the following represents documentation of the patient's current and past health status?
- Answers medical history
Which of the following contains the physician's findings based on an examination of the patient?
- Answers physical exam
What is the function of a consultation report? - Answers 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? - Answers 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? - Answers living will
Most ambulatory care settings can earn accreditation from all but this organization? - Answers
CARF
