C810 Section 1.1 Chapter 4 questions with complete solutions 2023/2024

C810 Section 1.1 Chapter 4What factors influence the content of the health record? - correct answer -provider preference - type of facility -accrediting and certifying bodies external standards and regulations. -state licensure standards -internal standards (medical staff bylaws) -federal programs promoting interoperability and patient data exchange Who provided the impetus for standardizing health records when i developed minimum standards for hospitals early in the 20th century? - correct answer The American College of Surgeons (ACS) Health Record - correct answer A health record can be defined as written or graphic information documenting facts and events during the rendering of patient care. Either paper or electronic format. What are the primary functions of the health record? - correct answer -Facilitate the ongoing care and treatment of patients -Support clinical decision-making & communication among clinicians -Document the services provided in support of reimbursement -Provide info for the evaluation of the quality & efficacy of the care provided -Provide info in support of medical research and education -Help facilitate the operational management of the facility -Provide info as required by local & national laws and regulations Longitudinal health record - correct answer Record compiled about an individual that contains health records from various encounters and from numerous healthcare delivery settings What are the benefits of the EHR? - correct answer -Ability to treat pts at multiple locations while having all the pts documentation available -simultaneous viewing of patient documentation -ability to document remotely -benefits related to aggregating data, reimbursement, and research What are the challenges of the EHR? - correct answer -privacy and security -data integrity -system downtime -interoperability -provider acceptance and training -patient education What are 3 ways patient health record data can be used aside from direct patient care? - correct answer 1. to determine if a particular clinical service is profitable or not 2. can be used to review what types of conditions are most common in the emergency department 3. can assist with looking for trends in patients who are readmitted t the hospital 4. can be used to educate providers of the effectiveness of particular treatments What two broad categories can all health records be classified into? - correct answer 1. administrative and demographic data 2. clinical data What kinds of demographic data is included in the patient's chart? - correct answer -Patient's name -Patient's phone number -Patient's Address -Patient's date of birth -Patient's SSN -Patient's next of kin Unique identifier - correct answer A combination of numbers or alphanumeric characters assigned to a particular patient