c810 - Exam Study Set 1 questions with complete solutions 2023/2024

c810 - Exam Study Set 1patient care and treatment. - correct answer What is the primary purpose of patient health information? Factors influencing the content of the health record include - correct answer The following factors are examples of? provider preference; process of care; data sets; external standards and regulations from accrediting and certifying bodies state licensure standard internal standards like medical staff bylaws. Joint Commission - correct answer Initially responsible for the accreditation of hospitals, the Joint Commission has since expanded its accreditation process to home health, long-term care, and other types of healthcare facilities. Centers for Medicare and Medicaid Services - correct answer is the division of the federal Department of Health and Human Services responsible for developing and enforcing regulations regarding the participation of healthcare providers in the Medicare program. The regulations for health record content and documentation were originally established in the Conditions of Participation—guidelines and regulations under which facilities are allowed to participate in Medicare and Medicaid programs. state licensure - correct answer regulations may include very specific requirements for the content, format, retention, and use of patient records. These regulations are established by state governments, usually under the direction of state departments of health. medical staff bylaws - correct answer outline the content of patient health records, identify the exact personnel who can enter information in health records, and may restate applicable Joint Commission and CMS requirements. In addition, bylaws describe the time limits for completing patient health records longitudinal health record - correct answer A _________________________________ is a birth-to-death record that acts as an ongoing reference for and about the patient. The problem with achieving a this type of record with a hybrid system is that the patient has paper records in multiple settings that cannot be linked. Orders - correct answer Directions given for drugs, devices, and healthcare treatments Physical Examination - correct answer Comprehensive assessment of patient to determine signs and symptoms Ancillary Notes - correct answer Records maintained by physical therapists, speech therapists, respiratory therapists, and other providers of special services Care Path - correct answer Protocol for the process of care History - correct answer Summary of background information about the patient's illness Advanced Directives - correct answer Statement of the patient's wishes or instructions for care D/C Summary - correct answer Conclusions at the termination of care Nursing Notes - correct answer Observations of the patient's response to treatment Emergency Record - correct answer Record that must contain the time and means of arrival and the name of the person transporting the patient to the facility Consultations - correct answer Opinions of specialists Source-oriented health record - correct answer This is the conventional or traditional method of maintaining paper-based health record