Question 1

Sally Smith is completing analysis of a patient's record and finds an original incident report in the record. Which action should she take?

Accepted Answer

The original incident report should be sent to the risk manager's office as it is not typically part of the patient's medical record.

Question 2

Dr. Smith documents in a patient's record that the patient may be released from the recovery room. This would be documented as part of the

Accepted Answer

The postanesthesia note is specifically designed to document the patient's status and readiness for release from the recovery room after anesthesia, reflecting the patient's recovery from anesthesia and ensuring they are stable for transfer.

Question 3

Dr. Jones reviews the following information located in the patient record. In which report is the information documented? $\begin{array}{|l|l|l|l|l|l|l|}
\hline \text { Date } & 1 / 2 / \mathrm{YYYY} & 1 / 3 / \mathrm{YYYY} & 1 / 4 / \mathrm{YYYY} & 1 / 5 / \mathrm{YYYY} & 1 / 6 / \mathrm{YYYY} & 1 / 7 / \mathrm{YYYY} \
\hline \text { Blood Pressure } & 130 / 75 & 128 / 78 & 120 / 75 & 130 / 80 & 135 / 80 & 130 / 78 \
\hline \text { Temperature } & 99.3 & 99.5 & 99.8 & 99.5 & 99.8 & 99.9 \
\hline \text { Weight } & 139 & 139 & 137 & 137 & 136 & 138 \
\hline
\end{array}$

Accepted Answer

The information documented includes blood pressure, temperature, and weight over a series of dates, which are typically recorded in a patient's vital signs record.

Question 4

Dr. Jones is the attending physician for Mary Smith, who was admitted for colitis. During her hospitalization Mary experiences chest pain. Dr. Jones asks Dr. Heart, a cardiologist, to evaluate Mary's chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the

Accepted Answer

Dr. Heart would document his examination, findings, recommendations, and opinions in a report of consultation. This is because he is providing a specialized evaluation at the request of the attending physician, Dr. Jones, to assess a specific issue (chest pain) that arose during the patient's hospitalization.

Question 5

Dr. Sharp, a surgeon, has designed a new form that she wants to use when she completes cataract surgery. Final approval of the form would be given by the

Accepted Answer

The forms committee is typically responsible for approving new forms used in a medical setting, as they oversee the standardization and management of documentation practices.

Question 6

Sally Jones assembles a patient record and organizes the following documents into a separate section of the record: face sheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered

Accepted Answer

The documents listed (face sheet, advance directives, informed consent, patient property form, and death certificate) are all related to administrative aspects of patient care, such as identification, legal permissions, and property management, rather than direct clinical or financial details of the treatment itself.

Question 7

Ms. RHIT is developing an audit tool to review records in preparation for The Joint Commission survey. Which of the following is a standard that should be included on the audit tool?

Accepted Answer

The Joint Commission standards emphasize the importance of documenting evidence of appropriate informed consent to ensure that patients are fully informed about their care. This is a critical aspect of patient rights and safety.

Question 8

The oncology committee has asked for data about patients admitted for chemotherapy with a length of stay greater than four days. The committee wants to determine patient weights on the day of admission as well as the day of discharge. This information can be located on the

Accepted Answer

The graphic record in a patient's medical chart includes vital signs, body measurements (including weight), and other pertinent data tracked over the course of the hospital stay, which would cover both admission and discharge weights.

Question 9

Which of the following is not documented as a part of a consultation report?

Accepted Answer

The signature of the requesting physician is not typically documented as a part of a consultation report. The report usually includes the consulting physician's signature, diagnosis and findings, and recommendations and opinions.

Question 10

In which of the following cases would documentation of an interval history be acceptable?

Accepted Answer

An interval history is appropriate when a patient is readmitted for the same condition shortly after discharge, as in the case of the 74-year-old readmitted for pneumonia.

Question 11

Review the following patient record entry, and determine in which report it would be documented. 
$\begin{array}{|l|l|}
\hline \text { Skin } & \text { No jaundice; reveals pale, cool, moist surface } \
\hline \text { Chest } & \text { Respirations normal } \
\hline \text { Lungs } & \text { Clear on inspection, percussion, and auscultation } \
\hline \text { Abdomen } & \text { No tenderness, guarding, or rigidity } \
\hline \text { Extremities } & \text { No significant findings } \
\hline \text { Genitalia } & \text { Normal } \
\hline \text { Rectal } & \text { Deferred } \
\hline
\end{array}$

Accepted Answer

This entry describes the findings from a physical examination, detailing observations and assessments of various body systems such as the skin, chest, lungs, abdomen, extremities, genitalia, and rectal area.

Question 12

Nurse Smith believes that inpatient Tom Jones needs physical therapy because his gait is unsteady when she works him. Which of the following would occur?

Accepted Answer

Nurse Smith would discuss her observations with Tom's attending physician because it is the physician who would evaluate the need for physical therapy and make the appropriate referral or order. Nurses play a crucial role in patient care by observing and reporting changes in a patient's condition, but they do not independently schedule therapies or change care plans without consulting the healthcare team, particularly the attending physician.

Question 13

Dr. Cook records the following as part of a history and physical examination: "Patient presents with abdominal pain of seven days' duration. Fever and chills for the last three days. Diagnosis at the time of admission: Rule out appendicitis vs. obstruction of colon." The diagnoses recorded are

Accepted Answer

The diagnoses recorded are differential diagnoses because Dr. Cook is considering multiple potential diagnoses (appendicitis vs. obstruction of colon) and has not yet determined the exact cause of the patient's symptoms.

Question 14

Dr. Health sees Jack in her office to monitor his blood chemistry. She completes an examination and orders blood tests. Her medical assistant completes the venipuncture. Charges for these services would be recorded on a(n)

Accepted Answer

An encounter form, also known as a superbill, is used to record services provided during a patient's visit, including examinations and procedures like blood tests.

Question 15

Which of the following observations would be found in the physical examination report?

Accepted Answer

Observations found in the physical examination report are those that can be directly observed or measured by the healthcare provider during the physical exam. Option C, "Abdomen soft and tender with no rebound tenderness," describes a finding from a physical examination of the abdomen, making it the correct choice. Options A and D describe the patient's history and review of systems, respectively, which are not part of the physical examination findings. Option B describes the patient's functional status, which is also not a direct observation from a physical examination.

Question 16

The major responsibility of a complete and accurate record rests with the:

Accepted Answer

The attending physician is primarily responsible for ensuring that a patient's medical record is complete and accurate, as they are directly involved in the patient's care and have the most comprehensive understanding of the patient's medical history and treatment.

Question 17

As Ms. RHIT assembles and analyzes a discharged obstetrical patient's record, she finds the forms listed below. Which should be pulled from the discharged patient's record? ​
Face sheet
Admission history and physical exam
Consents
Patient's property record
Insurance claim
Laboratory reports
Antepartum record (copy)
Labor and delivery record
Incident report
Postpartum record
​

Accepted Answer

Incident reports and insurance claims are not typically part of the patient's medical record and should be removed.

Question 18

A patient's record contains the following order: "Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks." This is an example of a

Accepted Answer

This is an example of a discharge order, as it indicates the patient is stable, has no complaints, and can be released home, with a follow-up appointment scheduled in the physician's office.

Question 19

Dr. Smith enters the following information as part of a progress note: "2/3/YYYY. Patient complains of right upper abdominal pain of four days' duration." This information represents the

Accepted Answer

The information provided by Dr. Smith represents the chief complaint, which is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the medical encounter, usually stated in the patient's words.

Question 20

Dr. Balby writes the following note: “Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant.” This information would be documented as part of the

Accepted Answer

The information provided by Dr. Balby pertains to the events occurring during labor and the delivery of the infant, which are documented in the labor and delivery record.

Quiz 6: Content of the Patient Record: Inpatient, Outpatient, and Physician Office