unit 4 thirty one though forty

Question 31 (2.5 points)

Which of the following would NOT be found on a discharge summary?

Question 31 options:

	Summary of laboratory results
	A brief history justifying the need for hospitalization
	Family history
	Patient condition at time of discharge

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Question 32 (2.5 points)

An attending physician’s request for a consult is called a(n):

Question 32 options:

	patient request.
	medical request.
	referral.
	consultation.

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Question 33 (2.5 points)

All of the following documentation guidelines have been developed by AHIMA EXCEPT:

Question 33 options:

	the health record should be organized systematically.
	only authorized individuals should be allowed to enter documentation in the health record.
	all entries in the health record should not be permanent.
	authors of entries should be clearly identified in the health record.

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Question 34 (2.5 points)

The acronym SOAP stands for:

Question 34 options:

	subjective, objective, assessment, plan.
	subjective, occupational, assessment, plan.
	subjective, operative, ailments, plan.
	subjective, objective, ailments, patient.

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Question 35 (2.5 points)

All orders, including medications, lab tests, and diagnostic tests, must be:

Question 35 options:

	dated.
	signed.
	verbally ordered.
	Both A and B

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Question 36 (2.5 points)

Which of the following is NOT an advantage of the PHR?

Question 36 options:

	Patients enter the information themselves.
	Patients can retrieve their own records.
	The record can be retrieved using the Internet.
	It can integrate information from many different providers.

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Question 37 (2.5 points)

Surgical procedures require which of the following?

Question 37 options:

	Anesthesia records
	Intraoperative records
	Informed consent for the procedure
	All of the above

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Question 38 (2.5 points)

The birth of a baby requires a document recording the birth to be signed and sent to the:

Question 38 options:

	admission office.
	parents.
	attending physician.
	state health department.

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Question 39 (2.5 points)

Who owns the patient health record?

Question 39 options:

	The facility or practice
	The patient
	The federal government
	The state

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Question 40 (2.5 points)

Health information professionals use which of the following to ensure quality patient records?

Question 40 options:

	Data sets
	Data elements
	HIM policies
	All of the above

 

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