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HIM FINAL EXAM (PART 1) 2024/25 | 607 QUESTIONS | WITH COMPLETE SOLUTIONS!!
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HIM FINAL EXAM (PART 1) 2024/25 | 607 QUESTIONS | WITH COMPLETE SOLUTIONS!!
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HIM FINAL EXAM (PART 1) 2024/25 | 607QUESTIONS | WITH COMPLETE SOLUTIONS!!
Joint Commission standards state that the patient record needs to contain
significant specific patient information related to _____, _____, and _____
provided. Answer - care, treatment, services
Patient records contain _______, ______, and ______ information. Answer -
clinical, case, demographic
CoP requires that each hospital establish a _________ and that hospitals must
maintain a _____ for all patients. Answer - medical record service
CoP requires that records must be accurately ______, promptly _______,
properly ______ and _____, and ________. Answer - written, completed, filed,
retained, accessible
For security purposes, CoP requires that the hospital must use a system of
__________ and _________ that ensures the integrity of _______. All record
entries be ________ and ______ promptly by appropriate person. Answer -
author identification, record maintenance, authentication, authenticated,
dated
CoP requires that the hospital record must contain information to justify _____,
________ and _______. Answer - diagnosis, admission, hospitalization
CoP requires that the record must contain information that describes patient's
________ and ________ to medications and services. It also must describe any
_______ to the patients condition and _______ actions taken. Answer -
progress, response, changes, follow through
,CoP requires records to be retained for at least _______. Answer - 5 years
CoP requires that hospital have a system of _______ and ______ to allow for
timely retrieval. Answer - coding, indexing
CoP requires that hospitals have procedure for ensuring _________ of patient
information. Answer - confidentiality
CoP states the records can only be released by hospital in accordance with
_________, ________, and ________. Answer - federal and state laws, court
order, subpoena
A valuable tool that documents the care and treatment of a patient. Answer -
patient record
Every report of the record must contain _________. Answer - patient
identification
Patient identifying information can include: ______, ________, and _______.
Answer - name, medical record number, date of birth
Every page/screen must include the patient's ______ and ________. Answer -
name, medical record number
Some patients insist on using an assumed name. This is called an ______.
Answer - alias
,True or False. Patients that use an assumed name will be reimbursed by their
insurance company. Answer - false
It is common for health care facilities to print the _______ or ______
physician's name and the _______ or ______ on each form. Answer -
attending, primary care, date of admission, visit
Imprints patient identification information on each report and allows for forms
to be imprinted prior to patient admission. Answer - addressograph machine
In addition to patient information, _______ must also be included on each
report in the record. Answer - facility identification
For a record to be admissible in a court of law, all patient record entries must
be ______ and ______. Answer - dated and timed
Providers must document entries ________ after care and treatment. Answer -
asap
_______ and ________ entries are not allowed in the record. Answer - pre-
dated, post-dated
When nurses summarize patient care at the end of a shift, documentation
should include ______ date and time the entry was made in the record.
Answer - actual
Facility identifying information should include ______, ______, and _______.
Answer - facility name, mailing address, and telephone number
Entries should be documented and signed by ______. Answer - author
, The patient record must contain any _______ provided to patient's family or
physician. Answer - communication
All fields on preprinted forms should be ______. Answer - completed
If an original entry is incomplete, the provider should _______ the entry.
Answer - amend
If documentation is reported only when a specific behavior occurs, then the
provider must indicate appropriate _________. Answer - charting instructions
Entries should be _______ with documentation in the record. Answer -
consistent
If documentation is contradictory, an ______ should be included. Answer -
explanation
Providers should not _______ lines or leave ______. Answer - skip, blanks
Do not generate a ______ until the previous form is filled. Answer - new form
If a new form is started, the provider should cross out any ___________ on the
previous form. Answer - remaining space
Blank space on the form raises the question that the record may be _________.
Answer - falsified
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