CRIS TEST UPDATED Questions and
CORRECT Answers
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
5. Tossing discarded copies of the patient's record without shredding or placement in a recycle
bin
6. Taking records or copies of records home for personal use
7. Leaving records open on counters, desks and any unauthorized area
8. Discussing patient information with friends or family members
9. Incorrect writing of mail addresses on envelopes
10. Releasing any sensitive records without the special authorization that may be required (drug,
alcohol, HIV, mental health, genetic,etc)
11. Unauthorized access or viewing of computer terminals
CORRECT Answers
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
5. Tossing discarded copies of the patient's record without shredding or placement in a recycle
bin
6. Taking records or copies of records home for personal use
7. Leaving records open on counters, desks and any unauthorized area
8. Discussing patient information with friends or family members
9. Incorrect writing of mail addresses on envelopes
10. Releasing any sensitive records without the special authorization that may be required (drug,
alcohol, HIV, mental health, genetic,etc)
11. Unauthorized access or viewing of computer terminals
