False (Level V) correct answers T/F: A Level I trauma center provides care from initial evaluation through stabilization.
Add the reason for the change correct answers When correcting erroneous information in a paper health record, which of the following is appropriate?
-Print "addendum" above ...
HIMT 1250 || Already Passed.
False (Level V) correct answers T/F: A Level I trauma center provides care from initial
evaluation through stabilization.
Add the reason for the change correct answers When correcting erroneous information in a paper
health record, which of the following is appropriate?
-Print "addendum" above entry
-Backdate to the date that the addendum covers
-Add the reason for the change
-Use a black pen to obliterate the entry
ambulatory care correct answers Patient history questionaires are most often used in what
setting?
-ambulatory care
-rehabilitative care
-home healthcare
-long-term
assisted living facility correct answers Which of the following is an example of a long-term care
setting?
-Assisted living facility
-Ambulatory surgery center
-Community mental health center
-Acute care hospital
medical history correct answers Represents documentation of the patient's current and past health
status.
hospital operative records correct answers The ambulatory surgery record contains information
most similar to which records?
False (patients must be informed about their rights) correct answers T/F: CMS does not require
healthcare providers to inform their patients about general patient rights afforded to them.
CARF (Commission on Accreditation of Rehabilitation Facilities) correct answers Primary
accreditation organization for facilities that treat individuals who have functional disabilities.
Insurance correct answers Patient Account Information includes.....
-Insurance
-Patient Gender
-Next of kin
-Race
,Emergency care correct answers Type of health record that contains information about the means
by which the patient arrived at the healthcare setting and documentation of care provided to
stabilize the patient.
True correct answers T/F: The Joint Commission surveys healthcare provider organizations for
clinical and operational practice compliance.
CoP (Conditions of Participation) correct answers General name for Medicare standards
impacting healthcare organizations.
True correct answers T/F: Auto-authentication is not in compliance with the CMS Interpretive
Guidelines for Hospitals.
Long-term care correct answers In what setting can an RAI/MDS and care plan be found in the
records of patients?
consultation report correct answers Documents opinions about the patient's condition from the
perspective of a physician not previously involved in the patient's care.
True correct answers T/F: The term ambulatory is the same as the term outpatient.
progress notes correct answers Which of the following is usually a component of acute care
patient records?
-means of arrival
-problem list
-minimum data set
-progress notes
care plan correct answers Type of progress note that provides healthcare professionals
impressions of patient problems with detailed treatment action steps.
physical examination correct answers Attending physician's assessment of the patient's current
health status.
False correct answers T/F: Healthcare provider organizations normally do not have patients sign
an acknowledgement addressing the fact that the healthcare provider organization is not
responsible for the loss or damage of the patient's valuables.
False ( about 50 years) correct answers Many electronic health records have only been around
since the early 2000s.
True correct answers T/F: When defining the legal health record, the healthcare provider must
assess the legal environment.
medical history correct answers In what part of the health record would the social and personal
history be found?
, True correct answers T/F: The overall goal of documentation standards is to ensure what is
documented in the health record is complete and accurately reflects the treatment provided to the
patient.
Physical exam correct answers Part of the health record that contains the physician's findings
based on an examination of the patient.
True correct answers T/F: An accreditation organization (AO) must participate in its own CMS
review in order to receive deemed status, allowing the AO to survey other healthcare providers
for compliance.
Semantic clinical drug term type correct answers Ingredient plus strength plus dose form is
known as the
-semantic clinical drug form term type
-semantic clinical drug component term type
-semantic clinical drug term type
-semantic branded drug term type
UHDDS (Uniform Hospital Discharge Data Set) correct answers This data set is collected by
acute care, short-term stay hospitals.
HCPCS II correct answers The standard for healthcare equipment under HIPAA.
Government regulation correct answers Decides which clinical terminology, classification, and
code system is selected as the standard.
CPT (Coding Procedural Terminology) correct answers A type of clinical terminology.
Sample type (Property timing sample (urine, serum)) correct answers Which of the following is
one of the parts of the LOINC fully specified name?
-Semantic Tag
-Sample Type
-Test Location
-Sample Size
home health correct answers The OASIS-C1 data elements originate from a Medicare-certified
_________ ________ agency.
RxNorm concept unique identifier correct answers The objective of RxNorm is to normalize
names of generic and branded drugs and attach a ________________ to that name.
-RxNorm current prescribable identifier
-RxNorm atom unique identifier
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