.png){kind=logo}
PDF Download
FREE MEDICAL AND STUDY GAMES ABOUT HIT CHAPTER 4
EXAM QUESTIONS
Actual Qs and Ans Expert-Verified Explanation
This Exam contains:
-Guarantee passing score -72 Questions and Answers -format set of multiple-choice -Expert-Verified Explanation Question 1: Patients statement about how she feels, including symptomatic information (ex. headache)
Answer:
subjective (S) Question 2: Incorporates patient registration, testing, and other services into one visit prior to inpatient admission and the results are incorporated into the patients record. (xrays, ekg, Lab testing)
Answer:
(PAT)- Preadmission testing
Question 3: To maintain patient records in a paper format
Answer:
Manual record Question 4: Documents the care and treatment recieved by patient admitted to the hospital
Answer:
Hospital inpatient record
Question 5: Includes medical staff-approved abbreviations, acronyms and symbols that can be documented into a patients record.
Answer:
Abbreviation List Question 6: The Joint Commission requires patient records to be completed 30 days after the patient is discharged
Answer:
Delinquent record Question 7: A provider whose signature the stamps represents must sign a statement that she or he alone will use the stamp to authenticate documents. Can be allowed in a facility, if allowed by state and federal law.
Answer:
signature stamp Question 8: Is a verbal order taken over the phone by a qualified professional from a physician (should be used in emergency situations)
Answer:
(T.O) - Telephone order Question 9: Also known as a verbal order. Is an order where the physician dictates an order in the presence of a responsible person (emergencies only)
Answer:
(V.O)- Voice Order Question 10: Documents the patients history, current medication, and vital signs on a variety of nursing forms, including nurses' notes, graphic charts and so on
Answer:
nursing assessment
Question 11: Listens to dictated information and keyboards the report.
Answer:
Medical transcriptionist
Question 12: Arranges reports in strict chronological date order
Answer:
Integrated record Question 13: A schedule that outlines the information that will be maintained, the time period for retention, and the manner in which information will be storedb
Answer:
record retention schedule Question 14: patient identification information; Patient's name, D.O.B, place of birth, mother's maiden name, S.S #
Answer:
Demographic data Question 15: Plans to learn more about the patients condition and the management of the conditions.
Answer:
Diagnostic/management plans
Question 16: The person who has legal responsibility for the patient
Answer:
Patient's represetative
Question 17: What's on each page of physician record?
Answer:
facilities name, mailing address, phone #
Question 18: 1.Document the word 'addendum'
- Current date and time, as well as original date and time for reference.
- Authenticate the addendum.
- State the reason for documenting the addendum. 5.
Answer:
Steps for ammendum
Question 19: Used to store records at a location separate from the facility
Answer:
Off-site storage/Remote storage Question 20: Length of time a facility will maintain an archived record. Based on fed and state laws.
Answer:
retention period
Question 21: Method's for authentication
Answer:
Written signatures, Countersignatures, Initials, Fax Signatures, Electronic signatures, Signature stamps Question 22: Divide the total # delinquent records by # of discharges in that period
Answer:
Delinquent record rate Question 23: 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
Answer:
Hospital outpatient record (Hospital Ambulatory Care record) Question 24: specific medications, goals, procedures, therapies, and treatments used to treat the patient
Answer:
therapuetic plans Question 25: Diagnostic, therapeutic, and educational plans to resolve the problems (ex. patient to take tylenol as needed for pain)
Answer:
plan (P)
.png)