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CRIS TEST 2024/2025 already graded A+
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CRIS TEST 2024/2025 already graded A+
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CRIS TESTPurposes of medical record - ANS1. To provide a communication tool between all healthcare
providers. A physician, nurse, and any healthcare professional that treats the patient will
complete documentation within the medical records
2. To provide documentation regarding diagnosis, treatment, and care of the patient while to find
a receiving services from a healthcare facility.
3. To provide information needed for medical billing of services rendered to the patient and
hospital financial management.
4. To provide a medium for analysis, study, and evaluation of the quality of care given to a
patient.
5. To assist in protecting the legal rights of the patients, the healthcare facility, and other
healthcare providers.
A master patient index (MPI) - ANSTool gathered to obtain the complete medical record. (Is
electronic medical database that holds information on every patient registered at a healthcare
organization.)
Discharge summary - ANSSummary of treatment the patient received. Includes the diagnosis of
their ailment. This is usually a transcribed report.
history and physical - ANSReflects the history of the patients disease or injury, as well as the
history of treatment. Usually transcribed, but may be hand written at the beginning of the
progress notes.
Electrocardiogram (EKG or ECG) & electroencephalogram (eeg) - ANSThese are specialized
tests for the heart (EKG) and the brain (EEG) that produce strips of findings that may be
mounted on individual pages.
Pulmonary function test (PFT) - ANSA test designed to measure how well the lungs are working
usually found in the respiratory section.
Operative report - ANSThis is a summary report of the operation including a description of what
was done and the findings.
Pathology report - ANSAn analysis of anything removed from the patient during the operation
(i.e. To check for cancer)
Continuity of care document (CCD) - ANSThe CCD is generated from an electronic health
record (EHR). It is a summary data set with demographic & clinical information about a patients
healthcare covering one of more encounters.
, Who owns the medical record? - ANSIt is the property of the facility in which it was created.
Which law is stronger if in conflict? State or federal? - ANSWhichever is stricter than the 2 with
more privacy protection will prevail.
Examples of a breach of confidentiality - ANS1. Disclosing the wrong patient's health
information or wrong type of information or dates.
2. Releasing records without a valid authorization
3. Elevator, cafeteria, or hallway talk about private patient information
4. Faxing records to an incorrect fax number
5. Tossing discarded copies of the patient's record without shredding or placement in a recycle
bin
6. Taking records or copies of records home for personal use
7. Leaving records open on counters, desks and any unauthorized area
8. Discussing patient information with friends or family members
9. Incorrect writing of mail addresses on envelopes
10. Releasing any sensitive records without the special authorization that may be required
(drug, alcohol, HIV, mental health, genetic,etc)
11. Unauthorized access or viewing of computer terminals
12. Speaking loudly on the telephone or in the work area where someone might overhear
patient health information
Who assess civil and criminal monetary penalties? - ANSAssessed by OCR for a breach of
confidentiality. Criminal breaches may be referred for prosecution by appropriate agencies such
as the Justice Department
Any improper disclosures should be reported when? - ANSIMMEDIATELY
HIPAA stands for - ANSHealth insurance portability and assurance act
Can you be made to put data on a flash drive? - ANSNope
HIPPA defines - ANSProtected health information as information in any form or medium that is
created or received by a healthcare facility and relates to the past, present or future condition of
a patient and identifies or could be used to identify an individual
HIPPA authorization requirements - ANS1. Identification of the persons or class of persons (i.e.
Physician practice; hospital) authorized to make the disclosure.
2. Identification of the persons or class of persons (i.e. Attorneys; insurance companies)
3. A description of the protected health information to be disclosed
4. A description of each purpose for the use or disclosure of the protected health information; it
is sufficient to put "at the request of the individual" on the authorization form, if authorization was
initiated by the patient
5. An expiration date or event
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