Medical Records Documentation Exam Questions And Answers 100% Pass.
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Course
Medical Records
Institution
Medical Records
Medical Records Documentation Exam
Questions And Answers 100% Pass.
What are the two main types of data of a Health Record? - answerAdministrative and clinical
Demographic data, socioeconomic data, financial data and consents are which part of the health
record - answerAdministrative
Admission...
Medical Records Documentation Exam
Questions And Answers 100% Pass.
What are the two main types of data of a Health Record? - answer✔Administrative and clinical
Demographic data, socioeconomic data, financial data and consents are which part of the health
record - answer✔Administrative
Admission/ registration Form,
Routine consent for Diagnosis and treatment, and special consents are examples of -
answer✔Administrative Data
What are the three main types of Clinical documentation? - answer✔Medical, Nursing and
Ancillary
What are some examples of common medical documentation and reports? - answer✔History and
Physical Examination (H&P), Progress Notes, Operative Reports, Physician Orders, Discharge
Summary (DS)
Nurse's notes, Graphic Chart, Intake, and Output Record (I&Os) are examples of what type of
the clinical documentation - answer✔Nursing documents & reports
What are some examples of common ancillary documents and reports? - answer✔Laboratory
Reports
Pathology Reports
Radiography Reports
EKG Reports
Physical Therapy Reports
Dietary Reports
What ultimately each document in the medical record should contain? - answer✔Sufficient
information to clearly identify the patient such as: patient name, health record number, date of
birth and gender
Explain JC and Medicare requirements for Admission/Discharge Record aka Face sheet -
answer✔IM 7.2 The medical record contains sufficient information to identify the patient,
support the diagnosis, justify the treatment, document the course and results, and promote
continuity of care among health care providers.
Routine Consent for Diagnosis and Treatment - answer✔authorization for routine care- things
like physical examination, routine laboratory tests and general medical care
authorization for release of information needed to process claim for reimbursement
release of liability for any personal items or valuable the patient keeps in hospital.
financial agreement - patient responsibility for bill.
Format - Sometimes printed on the back of the Admission/Discharge Record (face sheet) or may
be a separate form.
Responsibility - Usually Admissions/Registration staff obtain the patient's signature at the time
of admission.
Other - Also Known As (AKA) Conditions of Admission
Describe the types of services covered in physicians' orders - answer✔Date and time of the
order, signature of the physician who order the treatment and who picked up the order
List the various types of documentation written by physicians and explain their content and
functions - answer✔
Explain the conditions under which medical consultations should be ordered. - answer✔
Explain the function and content of discharge summaries - answer✔Content - A summary of the
patient's hospitalization that typically includes:
Reason for hospitalization
Hospital Course - chronological narrative of significant findings from exams and tests
Procedures performed and treatments
Patient's response
Condition on discharge - in non-ambiguous terms. Statements like "improved" or "better" are
discouraged. The physician should document how the patient is improved.
Discharge instructions: In terms of follow up, activity level, diet, medication, etc.
Final diagnoses are almost always listed in the discharge summary.
The discharge summary function as an information to other caregivers and facilitates continuity
of care. For patients discharged to ambulatory (outpatient) care, the clinical resume summarizes
previously levels of care.
Cite Joint Commission and Medicare standards for documentation of History and Physical
Examination, - answer✔Joint Commission - Requires:
Medical History including the chief complaint; details of the present illness; relevant past, social,
and family histories (appropriate to the patient's age); and a review of body systems.
required usually within 24 hours of admission and always before surgery is performed.
if recorded within 30 days prior to admission to the hospital, a legible copy may be included in
the health record and any interim changes recorded at time of admission.
if patient readmitted within 30 days for same or related condition, an interval H&P explaining
changed may be used.
Medicare COP - 482.24 (c)(2) All records must document the following, as appropriate:
(i)"Evidence of a physical examination, including a health history, performed no more than 7
days prior to admission or within 48 hours after admission."
Other - The facilities Medical Staff Rules and Regulations will state which individuals (such as
medical students, interns, etc.) require countersigning of reports by the
Cite Joint Commission and Medicare standards for documentation of Physician's Orders -
answer✔Joint Commission - Verbal orders of authorized individuals are accepted and
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