Deck 18: Documentation

Question 1

A patient's electronic medical record is used:

A) To assist in streamlining the sharing of medical information
B) To give healthcare providers access to patient medical information
C) To assist in preparation of health care statistics and research
D) All of the above

Answer 1

All of the above

Question 2

Through networks,the EHR can:

A) Allow patient's health information to be seen by anyone,anywhere
B) Prevent duplication of lab testing and treatments
C) Prevent polypharmacy
D) Both B and C

Answer 2

Both B and C

Question 3

Most physician office narrative records are kept in reverse chronological order,which means:

A) The records are in date order from the first patient visit
B) The most recent encounters are the first documents that you see
C) The record is divided by departments
D) The filing system keeps most recent patients at the beginning

Answer 3

The most recent encounters are the first documents that you see

Question 4

Who owns the patient's medical records?

A) The patient
B) The insurance company
C) The facility where the patient is treated
D) HIPAA

Question 5

The patient's medical record serves as:

A) Written communication between you and other healthcare professionals
B) A legal account of the patient's care
C) The patient's response to care given
D) All of the above

Question 6

What do many physicians worry about in relation to EHRs?

A) Privacy
B) Hackers
C) Costs
D) All of the above

Question 7

Of the following conditions,which one requires a special authorization for release of information?

A) HIV status
B) Alcohol use or abuse
C) Drug use or abuse
D) All of the above

Question 8

The use of multiple medications by a patient is known as:

A) Multidrug use
B) Polypharmacy
C) Polyprescriptive
D) Overmedication

Question 9

Acute care and long-term facilities keep records in chronological order,which means:

A) The beginning of the patient's care is at the beginning of the record
B) The record is compartmentalized
C) Most recent entries are at the beginning of the record
D) Tabs are placed on the record for each entry

Question 10

What may impact the decision for some physicians and healthcare facilities to convert to the EHR?

A) Frustration with electronics
B) Costs
C) Lack of privacy for records
D) Space for the computer stations

Question 11

Which of the following notes is written correctly?

A) I took the patient's vital signs
B) Vital signs taken
C) Mrs.Brown's vital signs were done
D) I went to the patient's room to take her vital signs
Completion
Complete each statement.

Question 12

Information contained in the medical record includes all of the following except:

A) Demographic information
B) Vital signs
C) Your personal opinion
D) Lab/x-ray reports

Question 13

The electronic health record (EHR)should:

A) Cost less than paper
B) Make documentation more complex
C) Improve patient care
D) Reduce the amount of documentation

Question 14

What is one item that may help clarify a situation for all who are involved in the patient's care?

A) Your detailed description written in the progress notes
B) A patient's quote
C) A note at the nurse's station to explain the details
D) A drawing

Question 15

Which of the following entities may get copies of your record without your written consent?

A) Your school
B) Your worker's compensation carrier
C) Your spouse
D) Your potential employer

Question 16

The best method of correcting an error in a patient record is:

A) Using correction fluid
B) Scribbling through the entire error
C) Striking through with a single line,providing date and a simple explanation
D) Using a dark marker to obliterate the error

Question 17

The most common format for recording a patient's health information is:

A) Exceptional
B) Listing
C) Paragraphs
D) Narrative

Question 18

A continuous narrative summary of the patient's care by physicians,nurses,and other healthcare professionals is the:

A) Flowchart
B) Progress notes
C) Medication record
D) Problem list

Question 19

A format for documenting repeated medical information,such as vital signs,separate from the narrative summaries is:

A) By exception
B) Narrative
C) Flowcharts
D) Graphic modules

Question 20

The initial government mandate was for all healthcare providers to convert to an electronic format by:

A) 2000
B) 2010
C) 2014
D) 2024

Question 21

All entries in the patient's medical record must be thorough,_______________,and professional.

Question 22

A medical record is both a medical and ___________document.

Question 23

In some facilities,an ___________report (adverse occurrence)form may be used to document an error in its entirety.

Question 24

In addition to reducing the amount of paper used,the electronic record saves ___________and increases the provider's access to the patient's medical information.
Chapter 18: Documentation

Question 25

Documentation should be ___________and not written as a narrative that includes unnecessary information.