Which of the Following is Documented in a Rehabilitation Service Record

Question 1 2.5 / 2.5 pts (CO 1) Which of the following clinical data elements is NOT usually documented in the acute-care health record? Clinical observations Medical history Correct! Immunization records Discharge summary See Chapter 4, pages 90–100. Question 2 2.5 / 2.5 pts (CO 1) Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? Autopsy report Operative report Pathology report Correct! Laboratory report General answer comments See Chapter 4, page 94. Question 3 2.5 / 2.5 pts (CO 1) What is the function of a consultation report? Provides a chronological summary of the patient’s medical history and illness Correct! Documents opinions about the patient’s condition from the perspective of a physician not previously involved in the patient’s care Concisely summarizes the patient’s treatment and stay in the hospital from the time of admission to the time of discharge Documents the physician’s instructions to other parties involved in providing care to a patient See Chapter 4, page 96. Question 4 2.5 / 2.5 pts (CO 1) Which of the following is NOT a function of the discharge summary? Ensuring the continuity of future care Correct! Providing information about the patient’s insurance coverage Providing information to support the activities of the medical staff review committee Providing concise information that can be used to answer information requests See Chapter 4, page 97. Question 5 2.5 / 2.5 pts (CO 1) Which of the following is NOT true about the surgical procedure documentation? It includes the anesthesia report Correct! It includes laboratory results It may include a pathology report It includes an operative report See Chapter 4, pages 94–95. Question 6 2.5 / 2.5 pts (CO 1) Which type of health record contains information about the means by which the patient arrived at the healthcare setÝng and documentation of care provided to stabilize the patient? Ambulatory care Long-term care Correct! Emergency care Rehabilitation care In addition to the care provided, emergency health record contains the method of arrival. Question 7 2.5 / 2.5 pts (CO 1) Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? Correct! Care plan Surgical note Flow record Vital signs record Question 8 2.5 / 2.5 pts (CO 1) An RAI/MDS and care plan are found in records of patients in _____. home healthcare Correct! long-term care behavioral healthcare rehabilitative care RAI/MDS means resident assessment instrument/minimum data set and is found in the records of nursing home (long-term care) residents. Question 9 2.5 / 2.5 pts (CO 1) Which of the following documents is usually found in a behavioral healthcare record? Correct! Psychiatric notes diagnostic procedures See Chapter 4, page 104. Question 10 2.5 / 2.5 pts (CO 1) Which of the following is documented in a rehabilitation service record? Patient assessment instrument Rehabilitation prognosis Correct! All of the above Question 11 2.5 / 2.5 pts (CO 1) Which of the following materials is NOT usually documented in an emergency care record? Patient’s instructions at discharge Time and means of the patient’s arrival Correct! Operative report Emergency care administered before arrival at the facility See Chapter 4, page 100. Question 12 2.5 / 2.5 pts (CO 1) Which of the following represents documentation of the patient’s current and past health status? Correct! Medical history Physical exam Physician orders Patient consent See Chapter 4, page 91. Question 13 2.5 / 2.5 pts (CO 1) Which of the following represents the attending physician’s assessment of the patient’s current health status? Medical history Correct! Physical exam Progress notes Discharge summary See Chapter 4, page 92. Question 14 2.5 / 2.5 pts (CO 1) Which of the following is expected to be documented in an operative report? Description of the procedure Estimated blood loss Post-operative diagnosis Correct! All of the above Question 15 2.5 / 2.5 pts (CO 1) A growth and development record may be found in what type of record? Rehabilitative care Correct! Pediatric care Behavioral health Obstetric care See Chapter 4, page 101. Question 16 2.5 / 2.5 pts (CO 1) Which type of health record may contain family and caregiver input? Correct! Behavioral health records Ambulatory surgery health records Emergency department health records Obstetric health records See Chapter 4, page 104. Cancel Question 17 2.5 / 2.5 pts (CO 1) Which of the following is a tool used to track paper-based health records? Requisition Compliance documentation Correct! Outguide MPI See Chapter 3, pages 59–66. Question 18 2.5 / 2.5 pts (CO 1) The overall goal of documentation standards is to _____. Correct! ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient ensure that the healthcare provider organization is reimbursed appropriately by payers ensure that the Centers for Medicare and Medicaid Services (CMS) do not find reason to fine the healthcare provider organization ensure physicians have access to the health record information they need to care for the patient Documentation standards ensure that the health record records the treatment provided to the patient. Question 19 2.5 / 2.5 pts (CO 1) When defining the legal health record, what must the healthcare provider do? Correct! Assess the legal environment Determine what the other healthcare providers are doing Determine what the other healthcare providers are doing Include only the paper components of the health record Part of the process to identify the legal health record is to access the legal environment. Question 20 2.5 / 2.5 pts (CO 1) When correcting erroneous information in a paper health record, which of the following is appropriate? Print addendum above the entry. Backdate to the date that the addendum covers. Correct! Add the reason for the change. Use a black pen to obliterate the entry. One of the steps in correcting an error is to document the reason for the change.