Domain 3: Health Records and Data Content Practice Exam

Employing the SOAP style of progress notes, choose the “assessment” statement from the following:

sciatica unimproved with hot pack therapy

in addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

discharge orders

The Joint Commission required that all medical records be completed within _________ following patient discharge.

30 days

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam of this report should be set at

24 hours after admission or prior to surgery

The primary focus of screen format design in a health record computer application should be to ensure that

the user is capturing essential data elements

An HIM professional was tasked with analyzing a group of medical records qualitatively for deficiencies. this would include

reviewing medical records for missing or ambiguous details.

The following data is required to be included in a patient health record, EXCEPT

copies of all claims submitted

Based on the following documentation in an acute care record, determine where would you expect this excerpt to appear?

With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line which was taped to skin and used for administration of drugs during resuscitation.

operative record

You need to retrieve information on a particular physician in your facility. Specifically, you need to know how many cases he saw during the month of May. What would be your best source of information?

physician index

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

attending physician

A final progress note is appropriate as a discharge summary for a hospitalization in which the patient

was an obstetric admission with a normal delivery and no complications

In which registry would you expect to find an Injury Severity Score (ISS)?

trauma registry

Which one of the following would be an essential item captured on the physical exam?

general appearance as assessed by the physician

Under the Patient Self-Determination Act of 1990, evidence of advance directives

is require to be documented in the health record.

The Health Information Department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which of the following would be the best source to identify the necessary charts?

disease index

Dr. Smith failed to dictate an operative report. He is notified through the

chart deficiency system

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave

documented in both the progress notes and the discharge summary.

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of

qualitative review.