FREE MEDICAL AND STUDY GAMES ABOUT HIT 114 CH. 4

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FREE MEDICAL AND STUDY GAMES ABOUT HIT 114 CH. 4

EXAM QUESTIONS

Actual Qs and Ans Expert-Verified Explanation

This Exam contains:

-Guarantee passing score -92 Questions and Answers -format set of multiple-choice -Expert-Verified Explanation

Question 1: Authentication

Answer:

A patient record entry signed by the author

Question 2: voice order (V.O.)

Answer:

physician dictates an order in the presence of a responsible person; this is no longer accepted as standard practice by health care facilities and is documented in emergencies only

Question 3: subjective(S)

Answer:

portion of the POR progress note that documents the patient's statement about how they feel, including symptomatic information

Question 4: Document Imaging

Answer:

Provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media; aka optical dick imaging

Question 5: plan (P)

Answer:

portion of the POR progress note that documents diagnostic, therapeutic and eduacational plans to resolve the problems

Question 6: Amending Patient records

Answer:

Correction of an incorrect patient record entry by the author of the original entry

Question 7: preadmission testing (PAT)

Answer:

incorporates patient registration, testing, and other services into one visit prior to inpatient admission with the results incorporated into the patient's record

Question 8: objective(O)

Answer:

portion of the POR progress note that documents observations about the patient, such as physical findings or lab or X-ray results

Question 9: Electronic Medical Record (EMR)

Answer:

automated record system that documents patient care using a computer with a keyboard, mouse, opitcal pen device, voice recognition system, scanner, or touch screen

Question 10: problem list

Answer:

documentation in the POR that acts as a table of contents for the patient record because it is filed at the beginning og the record and contains a list of the patient's problems

Question 11: magnetic degaussing

Answer:

Destruction of electronic records by altering fields on a computer medium

Question 12: nursing assessment

Answer:

documents patient's history, cuttent medications, and vital signs on a variety of nursing forms, including nurses notes and graphic charts

Question 13: statue of limitations

Answer:

refers to the time period after which a lawsuit cannot be filed

Question 14: longitudinal patient record

Answer:

records from different episodes of care, providers, and facilities, that are linked to form a view, over time, of a patient's health care encounters

Question 15: Audit Trail

Answer:

List of all changes made to patient documentation in an electronic health record system, including all transactions and activities, date, time, and user who performed the transaction Question 16: ASTM E 1762-Standard Guide for Authentication of Healthcare Information

Answer:

Document intended to complement standards developed by other organizations and define a document structure for use by electronic signature process, minimum requirements for different use with electronic signature mechanisms, acceptable electronic signatur

Question 17: integrated record

Answer:

Patient record format that usually arranges reports in strict chronological date order

Question 18: Hospital Outpatient Record

Answer:

documents services received by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient surgery

Question 19: Electronic Health Record (EHR)

Answer:

aka computer based patient record. automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient

Question 20: Indexed

Answer:

identification of scanned pages according to a unique idnetification number making it unnecessary to scan documents for the same patient at the time

Question 21: Clinical data repository

Answer:

allows for the collection of all clinical data in one centralized database and provides easy access to data in electronic ot printed form to the patient's clinical history

Question 22: transfer note

Answer:

documented when a patient is being transferred to anothe facility

Question 23: Digital archive

Answer:

storage solution that consolidates electronic records on a computer server for management and retrieval

Question 24: Dianostic managment plans

Answer:

category of POR's initial plan that documents the patient's condition and management of the condition

Question 25: potentially compensable event (PCE)

Answer:

an accident of medical error that results in personal injury or loss of property

Question 26: Age of Majority

Answer:

age of consent