CRIS Test – Questions With Valid Solutions
Purposes of medical record Correct Answer - 1. To provide a
communication tool between all healthcare providers. A physician,
nurse, and any healthcare professional that treats the patient will
complete documentation within the medical records
2. To provide documentation regarding diagnosis, treatment, and
care of the patient while to find a receiving services from a
healthcare facility.
3. To provide information needed for medical billing of services
rendered to the patient and hospital financial management.
4. To provide a medium for analysis, study, and evaluation of the
quality of care given to a patient.
5. To assist in protecting the legal rights of the patients, the
healthcare facility, and other healthcare providers.
A master patient index (MPI) Correct Answer - Tool gathered
to obtain the complete medical record. (Is electronic medical
database that holds information on every patient registered at a
healthcare organization.)
Discharge summary Correct Answer - Summary of treatment
the patient received. Includes the diagnosis of their ailment. This is
usually a transcribed report.
history and physical Correct Answer - Reflects the history of
the patients disease or injury, as well as the history of treatment.
Usually transcribed, but may be hand written at the beginning of the
progress notes.
Electrocardiogram (EKG or ECG) & electroencephalogram (eeg)
Correct Answer - These are specialized tests for the heart (EKG)
, and the brain (EEG) that produce strips of findings that may be
mounted on individual pages.
Pulmonary function test (PFT) Correct Answer - A test
designed to measure how well the lungs are working usually found
in the respiratory section.
Operative report Correct Answer - This is a summary report of
the operation including a description of what was done and the
findings.
Pathology report Correct Answer - An analysis of anything
removed from the patient during the operation (i.e. To check for
cancer)
Continuity of care document (CCD) Correct Answer - The CCD
is generated from an electronic health record (EHR). It is a summary
data set with demographic & clinical information about a patients
healthcare covering one of more encounters.
Who owns the medical record? Correct Answer - It is the
property of the facility in which it was created.
Which law is stronger if in conflict? State or federal? Correct
Answer - Whichever is stricter than the 2 with more privacy
protection will prevail.
Examples of a breach of confidentiality Correct Answer - 1.
Disclosing the wrong patient's health information or wrong type of
information or dates.
2. Releasing records without a valid authorization
3. Elevator, cafeteria, or hallway talk about private patient
information
4. Faxing records to an incorrect fax number
Purposes of medical record Correct Answer - 1. To provide a
communication tool between all healthcare providers. A physician,
nurse, and any healthcare professional that treats the patient will
complete documentation within the medical records
2. To provide documentation regarding diagnosis, treatment, and
care of the patient while to find a receiving services from a
healthcare facility.
3. To provide information needed for medical billing of services
rendered to the patient and hospital financial management.
4. To provide a medium for analysis, study, and evaluation of the
quality of care given to a patient.
5. To assist in protecting the legal rights of the patients, the
healthcare facility, and other healthcare providers.
A master patient index (MPI) Correct Answer - Tool gathered
to obtain the complete medical record. (Is electronic medical
database that holds information on every patient registered at a
healthcare organization.)
Discharge summary Correct Answer - Summary of treatment
the patient received. Includes the diagnosis of their ailment. This is
usually a transcribed report.
history and physical Correct Answer - Reflects the history of
the patients disease or injury, as well as the history of treatment.
Usually transcribed, but may be hand written at the beginning of the
progress notes.
Electrocardiogram (EKG or ECG) & electroencephalogram (eeg)
Correct Answer - These are specialized tests for the heart (EKG)
, and the brain (EEG) that produce strips of findings that may be
mounted on individual pages.
Pulmonary function test (PFT) Correct Answer - A test
designed to measure how well the lungs are working usually found
in the respiratory section.
Operative report Correct Answer - This is a summary report of
the operation including a description of what was done and the
findings.
Pathology report Correct Answer - An analysis of anything
removed from the patient during the operation (i.e. To check for
cancer)
Continuity of care document (CCD) Correct Answer - The CCD
is generated from an electronic health record (EHR). It is a summary
data set with demographic & clinical information about a patients
healthcare covering one of more encounters.
Who owns the medical record? Correct Answer - It is the
property of the facility in which it was created.
Which law is stronger if in conflict? State or federal? Correct
Answer - Whichever is stricter than the 2 with more privacy
protection will prevail.
Examples of a breach of confidentiality Correct Answer - 1.
Disclosing the wrong patient's health information or wrong type of
information or dates.
2. Releasing records without a valid authorization
3. Elevator, cafeteria, or hallway talk about private patient
information
4. Faxing records to an incorrect fax number
