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CHAPTER 4 EHIMPP-INTRODUCTION TO THE PATIENT RECORD STUDY GUIDE SOLUTIONS $10.49   Add to cart

Exam (elaborations)

CHAPTER 4 EHIMPP-INTRODUCTION TO THE PATIENT RECORD STUDY GUIDE SOLUTIONS

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  • 2025/2026
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CHAPTER 4 EHIMPP-INTRODUCTION TO THE PATIENT RECORD STUDY GUIDE SOLUTIONS CLINICAL DATA - ANSWER-LAB REPORTS, PROBLEM LIST, VITAL SIGNS ADMINISTRATIVE DATA - ANSWER-not related to care or treatment provided; includes demographic, financial, and consent info AUTHENTICATION - ANSWER-only the au...

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  • October 30, 2024
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  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • 2025/2026
  • 2025/2026
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©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED

FIRST PUBLISH OCTOBER 2024




CHAPTER 4 EHIMPP-INTRODUCTION TO

THE PATIENT RECORD STUDY GUIDE

SOLUTIONS


CLINICAL DATA - ANSWER✔✔-LAB REPORTS, PROBLEM LIST, VITAL SIGNS


ADMINISTRATIVE DATA - ANSWER✔✔-not related to care or treatment provided; includes demographic,

financial, and consent info


AUTHENTICATION - ANSWER✔✔-only the author of an entry can authenticate that an entry is accurate


FEDERAL REGULATIONS AND INTERPRETIVE GUIDELINES FOR HOSPITALS - ANSWER✔✔-specifies

authentication methods


Electronic signature - ANSWER✔✔-a digitized image of a handwritten signature used for authentication


Types of Authentication - ANSWER✔✔-signature by original author, countersignature, initials


COUNTERSIGNATURE - ANSWER✔✔-Authentication by a second individual in addition to the signature of

the original author of an entry


PATIENT RECORD - ANSWER✔✔-medicolegal document, If it wasn't documented, it wasn't done
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, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED

FIRST PUBLISH OCTOBER 2024




PROPER PROCEDURE FOR CORRECTING A PROGRESS NOTE - ANSWER✔✔-line through it, date, time,

signature, "error" and correction


AUTHORIZED - ANSWER✔✔-who can make entries to a medical record


Dangerous Abbreviations - ANSWER✔✔-a list of abbreviations, acronyms, and symbols prohibited by the

Joint Commission


AUDIT TRAIL - ANSWER✔✔-a technical control created by an EHR system that lists all transactions and

activities


Verbal order ( VO ) - ANSWER✔✔-Order made over the telephone; voice order


universal chart order - ANSWER✔✔-When facilities organize reports in same order for both inpatient and

discharged patient records, the facility is using a:


benefits of universal chart order - ANSWER✔✔-saves processing time because reorganization is

unnecessary


PAT - ANSWER✔✔-preadmission testing


Impact of PAT to inpatient LOS - ANSWER✔✔-physician can provide timely treatment because he has all

of the data prior to encounter


EXAMPLES OF PAT - ANSWER✔✔-chest x-ray, EKG, lab tests


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