Which of the following does NOT apply to medical record documentation?
complete
timely
accurate
length
What will the electronic health record reduce?
cost
medical errors
coding jobs
confidentiality issues
Which of the following is NOT considered a common documentation error or deficiency?
late entry
date inconsistency
location discrepancy
missing/incorrect patient information
Which of the following is included in patient demographics?
name, address, and telephone number
date of birth and gender
insurance and billing information
all of the above
Which of the following would NOT be considered a documentation error?
missing patient's date of birth
inconsistencies in date
missing operative report
missing physician's signature
Implementation of the electronic health record offers many challenges. Which would NOT be considered a critical challenge?
control of cost
maintaining confidentiality
ease of storage
maintaining security of the healthcare record
Response to treatment, change in patient's diagnosis, and progress towards discharge are all pieces of information found in this medical report.
Progress Note
History and Physical Examination
Procedure Note
Discharge Summary
"The patient had mumps and measles as a child. She has suffered from community-acquired pneumonia twice in the past 15 years. Her last hospitalization occurred earlier this year after being involved in a car accident. The patient's clavicle was repaired at that time." This information is found on the ___ section of History & Physical exam.
Review of Systems
Social History
Physical Examination
Past Medical History
Determine which of the following report types would ONLY be found in an inpatient medical record.
Consultation
Operative Report
Which of the following is something that makes implementing EHR difficult?
they are costly to maintain
employees must be trained on a new system
EHR systems can be hacked and medical information exposed
The ___ is the name of the U.S. government agency tasked with guiding the nationwide implementation of health information technology.
Regional Health Information Organization
Office of the National Coordinator
Health Level Seven
none of the above
One of the benefits to using an encoder is ___
speed and efficiency
security
more bandwidth
Medical professionals can use the ___ to identify, match, merge and cleanse patient records to create an index to obtain a complete view of a patient.
nationally organized patient index
system-wide patient control index
enterprise-wide master patient index
