Question 1

The physician who is primarily responsible for coordinating the care of the patient in the hospital is the ___________.

Accepted Answer

attending physician

Question 2

There may be a(n) ______________ on the patient's wristband, readable by machine, which connects the patient to his or her medical record.

Accepted Answer

bar code
barcode

Question 3

Describe the events that will occur when a patient is admitted to an acute care facility for a surgical procedure. What caregivers will be involved with the patient?

Accepted Answer

Answers will vary but should focus on the patient movement rather than the documentation. Patient Registration checks the patient in. Preadmission testing may occur, in which the patient has blood drawn by a phlebotomist, has an x-ray taken by a radiology technician, and gives a urine sample to a laboratory technician. Prior to the operation, the physician examines the patient to ensure that there are no complications or contraindications. If the patient has a chronic condition, such as heart problems, a consultation to clear the patient for surgery may be required. On the day of the operation, the patient checks in with Patient Registration. Nursing staff prepare the patient for the operation. The surgeon performs the procedure, assisted by nursing, and nursing staff care for the patient during recovery. If the patient is receiving certain types of anesthesia, an anesthesiologist will meet with the patient prior to the operation, administer the anesthesia during the operation, and follow-up with the patient after the operation.

Question 4

A cardiology consultation is typically requested by:

Accepted Answer

A)  Attending physician 
B)  Nursing 
C)  Patient 
D)  All of the above 
A)  Attending physician 
B)  Nursing 
C)  Patient 
D)  All of the above

Question 5

A problem-focused physical examination focuses on which of the following body areas and organ systems?

Accepted Answer

A)  All body areas and organ systems. 
B)  Only the head, neck, chest and abdomen 
C)  Only the patient's general appearance, and his or her vital signs 
D)  Only the body area(s) or organ system(s) affected 
A)  All body areas and organ systems. 
B)  Only the head, neck, chest and abdomen 
C)  Only the patient's general appearance, and his or her vital signs 
D)  Only the body area(s) or organ system(s) affected

Question 6

What is the documentation standard for History and Physicals (H&Ps) established by the Joint Commission?

Accepted Answer

In an acute care facility, CMS (and cons

Question 7

What are essential elements in the operative report? List at least five.

Accepted Answer

The operative report lists the preoperat

Question 8

All of the following are elements of the UHDDS EXCEPT:

Accepted Answer

A)  Principal diagnosis 
B)  Race 
C)  Marital status 
D)  Disposition 
A)  Principal diagnosis 
B)  Race 
C)  Marital status 
D)  Disposition

Question 9

A predetermined set of instructions for a specific set of blood tests, x-rays, or other procedures is called:

Accepted Answer

A)  Plan of care 
B)  Protocol 
C)  Utilization review 
D)  Verbal orders 
A)  Plan of care 
B)  Protocol 
C)  Utilization review 
D)  Verbal orders

Question 10

What is the purpose of the admission consent form? Why do patients have to sign this, and what permissions are given to the health care facility when a patient signs?

Accepted Answer

The general consent form also contains a

Question 11

The attending physician provides a(n) _____________ to explain the reason for admission.

Accepted Answer

The answer of The attending physician provides a(n) _____________ to...

Question 12

When a patient is first seen by a physician in any health care setting, the physician generally records the patient's chief complaint, pertinent family and social data, and a review of the patient's body systems. This record is called the ________.

Accepted Answer

history an

Question 13

Which of the following is an element of an acute care admission record?

Accepted Answer

A)  Patient's previous operations 
B)  Type of dwelling in which the patient lives 
C)  Name of patient's employer 
D)  Patient's height and weight 
A)  Patient's previous operations 
B)  Type of dwelling in which the patient lives 
C)  Name of patient's employer 
D)  Patient's height and weight

Question 14

List the UHDDS elements of a patient abstract. Explain how this information is captured.

Accepted Answer

See Table 4-8 in text. This in

Question 15

The extent and complexity of a history and physical are dictated by:

Accepted Answer

A)  TJC guidelines 
B)  DHHS guidelines 
C)  Data needed to evaluate the patient's problem 
D)  All of the above 
A)  TJC guidelines 
B)  DHHS guidelines 
C)  Data needed to evaluate the patient's problem 
D)  All of the above

Question 16

Laboratory tests performed at the time of the patient's admission help identify preexisting infections conditions. An infection identified after 48 hours of hospitalization is called a ____________ infection, and is attributed to the facility.

Accepted Answer

The answer of Laboratory tests performed at the time of...

Question 17

Which of the following should be collected during the patient registration process?

Accepted Answer

A)  A plan of care, the measures to treat the patient's condition or disease 
B)  An advance directive, to specify the patient's wishes for his/her care 
C)  A discharge summary, to recap the patient's stay 
D)  A history, to document the patient's previous treatments 
A)  A plan of care, the measures to treat the patient's condition or disease 
B)  An advance directive, to specify the patient's wishes for his/her care 
C)  A discharge summary, to recap the patient's stay 
D)  A history, to document the patient's previous treatments

Question 18

All of the following are always elements of a physician's order EXCEPT:

Accepted Answer

A)  Date 
B)  Physician's signature 
C)  Initials/signature of the individual executing the order 
D)  Reason/rationale for the order 
A)  Date 
B)  Physician's signature 
C)  Initials/signature of the individual executing the order 
D)  Reason/rationale for the order

Question 19

Obstetrical records differ from other types of acute care records because:

Accepted Answer

A)  Prenatal care data is collected earlier and transferred to the hospital 
B)  Obstetricians are not required by the TJC to collect a patient history and physical 
C)  The newborn is not considered an admission 
D)  The mother is not considered an admission 
A)  Prenatal care data is collected earlier and transferred to the hospital 
B)  Obstetricians are not required by the TJC to collect a patient history and physical 
C)  The newborn is not considered an admission 
D)  The mother is not considered an admission

Question 20

__________ is the care provided through the use of mobile technology that allows care providers to view and consult patients from satellite locations.

Accepted Answer

The answer of __________ is the care provided through the...

The physician who is primarily responsible for coordinating the care of the patient in the hospital is the ___________.

There may be a(n) ______________ on the patient's wristband, readable by machine, which connects the patient to his or her medical record.

Describe the events that will occur when a patient is admitted to an acute care facility for a surgical procedure. What caregivers will be involved with the patient?

A cardiology consultation is typically requested by:

A problem-focused physical examination focuses on which of the following body areas and organ systems?

What is the documentation standard for History and Physicals (H&Ps) established by the Joint Commission?

What are essential elements in the operative report? List at least five.

All of the following are elements of the UHDDS EXCEPT:

A predetermined set of instructions for a specific set of blood tests, x-rays, or other procedures is called:

What is the purpose of the admission consent form? Why do patients have to sign this, and what permissions are given to the health care facility when a patient signs?

The attending physician provides a(n) _____________ to explain the reason for admission.

When a patient is first seen by a physician in any health care setting, the physician generally records the patient's chief complaint, pertinent family and social data, and a review of the patient's body systems. This record is called the ________.

Which of the following is an element of an acute care admission record?

List the UHDDS elements of a patient abstract. Explain how this information is captured.

The extent and complexity of a history and physical are dictated by:

Laboratory tests performed at the time of the patient's admission help identify preexisting infections conditions. An infection identified after 48 hours of hospitalization is called a ____________ infection, and is attributed to the facility.

Which of the following should be collected during the patient registration process?

All of the following are always elements of a physician's order EXCEPT:

Obstetrical records differ from other types of acute care records because:

__________ is the care provided through the use of mobile technology that allows care providers to view and consult patients from satellite locations.

Health Care Delivery Systems

Collecting Health Care Data

Electronic Health Records

Health Information Management Processing

Code Sets

Reimbursement

Health Information Management Issues in Other Care Settings

Managing Health Records

Statistics

Quality and Uses of Health Information

Confidentiality and Compliance

Him Department Management

Training and Development

Filters

Exam 4: Acute Care Records

The physician who is primarily responsible for coordinating the care of the patient in the hospital is the ___________.

There may be a(n) ______________ on the patient's wristband, readable by machine, which connects the patient to his or her medical record.

Describe the events that will occur when a patient is admitted to an acute care facility for a surgical procedure. What caregivers will be involved with the patient?

A cardiology consultation is typically requested by:

A problem-focused physical examination focuses on which of the following body areas and organ systems?

What is the documentation standard for History and Physicals (H&Ps) established by the Joint Commission?

What are essential elements in the operative report? List at least five.

All of the following are elements of the UHDDS EXCEPT:

A predetermined set of instructions for a specific set of blood tests, x-rays, or other procedures is called:

What is the purpose of the admission consent form? Why do patients have to sign this, and what permissions are given to the health care facility when a patient signs?

The attending physician provides a(n) _____________ to explain the reason for admission.

When a patient is first seen by a physician in any health care setting, the physician generally records the patient's chief complaint, pertinent family and social data, and a review of the patient's body systems. This record is called the ________.

Which of the following is an element of an acute care admission record?

List the UHDDS elements of a patient abstract. Explain how this information is captured.

The extent and complexity of a history and physical are dictated by:

Laboratory tests performed at the time of the patient's admission help identify preexisting infections conditions. An infection identified after 48 hours of hospitalization is called a ____________ infection, and is attributed to the facility.

Which of the following should be collected during the patient registration process?

All of the following are always elements of a physician's order EXCEPT:

Obstetrical records differ from other types of acute care records because:

__________ is the care provided through the use of mobile technology that allows care providers to view and consult patients from satellite locations.

Health Care Delivery Systems

Collecting Health Care Data

Electronic Health Records

Health Information Management Processing

Code Sets

Reimbursement

Health Information Management Issues in Other Care Settings

Managing Health Records

Statistics

Quality and Uses of Health Information

Confidentiality and Compliance

Him Department Management

Training and Development

Filters