Chapter 4: Content of the Health
Record questions n answers graded
A+
4.1 What is the primary purpose of patient health information?
The primary purpose of patient health record is to document and support patient care services.
What are six other purposes or uses of patient health information?
1) Support clinical decision making and communication among clinicians. 2) Document the
service provided to the patient in support of reimbursement. 3) Provide information for the
evaluation of the quality and efficacy of the care provided. 4) Provide information in support in
support of medical research and education. 5) Help facilitate the operational management of
the facility. 6) Provide information as required by locale and national laws and regulations
What factors influence the content of the health record?
1) Provider preference 2) The process of providing care. 3) health care settings 4) Accrediting
and certifying bodies' external standards 5) state licensure standards. 6)internal standards such
as medicale staff bylaws that outline the requirements for content of the health record. 7)
meaningful use incentives
What is the role of each of the following in the development of standards for health
information: Joint Commission, Centers for Medicare and Medicaid Services, state licensure,
and medical staff bylaws?
, Joint Commission: Assumes responsibility for the accreditation of the health care facilities. His
surveyors routinely review the health records of current patients to obtain knowledge about the
facility's performance and process of care. CMS: responsible for developing and enforcing
regulations regarding the participation of healthcare providers in the medicare program.
Published guidelines for documenting histories and physical examinations and medical decision
making that affect physician reimbursement. State Licensure: Every state has licensure
regulations that healthcare facilities must meet in order to operate. Medical Staff bylaws:
Bylaws, rules and regulations are developed by medical staff and approved by the board of
Trustees or governing body in the healthcare facilities.
Why is a longitudinal health record valuable, and why is a longitudinal health record in a hybrid
system difficult to achieve?
It is valuable because all the informaion about a patient is maintained and accessible. It serves
as a reference of past history and helps the provider avoid repetition of details and duplication
of testing for the same conditions. Help to prevent medical error.
Who is responsible for ensuring the quality of health record documentation?
The provider of care.
4.2 Directions given for drugs, devices, and healthcare treatments.
Orders
Comprehensive assessment of patients to determine signs and symptoms
Physical examination
Record questions n answers graded
A+
4.1 What is the primary purpose of patient health information?
The primary purpose of patient health record is to document and support patient care services.
What are six other purposes or uses of patient health information?
1) Support clinical decision making and communication among clinicians. 2) Document the
service provided to the patient in support of reimbursement. 3) Provide information for the
evaluation of the quality and efficacy of the care provided. 4) Provide information in support in
support of medical research and education. 5) Help facilitate the operational management of
the facility. 6) Provide information as required by locale and national laws and regulations
What factors influence the content of the health record?
1) Provider preference 2) The process of providing care. 3) health care settings 4) Accrediting
and certifying bodies' external standards 5) state licensure standards. 6)internal standards such
as medicale staff bylaws that outline the requirements for content of the health record. 7)
meaningful use incentives
What is the role of each of the following in the development of standards for health
information: Joint Commission, Centers for Medicare and Medicaid Services, state licensure,
and medical staff bylaws?
, Joint Commission: Assumes responsibility for the accreditation of the health care facilities. His
surveyors routinely review the health records of current patients to obtain knowledge about the
facility's performance and process of care. CMS: responsible for developing and enforcing
regulations regarding the participation of healthcare providers in the medicare program.
Published guidelines for documenting histories and physical examinations and medical decision
making that affect physician reimbursement. State Licensure: Every state has licensure
regulations that healthcare facilities must meet in order to operate. Medical Staff bylaws:
Bylaws, rules and regulations are developed by medical staff and approved by the board of
Trustees or governing body in the healthcare facilities.
Why is a longitudinal health record valuable, and why is a longitudinal health record in a hybrid
system difficult to achieve?
It is valuable because all the informaion about a patient is maintained and accessible. It serves
as a reference of past history and helps the provider avoid repetition of details and duplication
of testing for the same conditions. Help to prevent medical error.
Who is responsible for ensuring the quality of health record documentation?
The provider of care.
4.2 Directions given for drugs, devices, and healthcare treatments.
Orders
Comprehensive assessment of patients to determine signs and symptoms
Physical examination
