Which two major types of data are contained in the health record? - correct answer clinical,
administrative
Which term refers to state or county
... [Show More] regulations that healthcare facilities must meet to be permitted to provide care? - correct answer licensure
Which international accrediting organization began a hospital accreditation program in the US in 2008? - correct answer DNV (Det Norske Veritas)
Facilities receiving accreditation by an accrediting organization with deemed status by Medicare do not need to undergo Medicare certification _________________. - correct answer surveys
Which group focuses on accreditation of managed care? - correct answer NCQA (National Committee for Quality Assurance)
Which group focuses on accreditation of rehabilitation programs and services? - correct answer CARF (Commission on Accreditation of Rehabilitation Facilities)
Which accreditation organization provides standards for the widest variety of healthcare facilities? - correct answer The Joint Commission
What documents the patient's chief complaint, present illness, and review of systems? - correct answer medical history
What documents the clinical opinion of a physician other than the primary physician? - correct answer consultation report
What summarizes the patient's problems and includes a detailed treatment plan? - correct answer care plan
Which type of consent is written or spoken? - correct answer expressed
Which report provides information on tissue removed during a procedure? - correct answer pathology
Which record includes sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores? - correct answer newborn
The patient's date of birth, name of next of kin, and type of admission are considered to be patient ___________________ information. - correct answer demographic
Which administrative document provides information on the patient's desires for healthcare for use if the patient is incapacitated? - correct answer advance directive
Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentation of care provided to stabilize the patient? - correct answer emergency care
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record? - correct answer ambulatory care
The ambulatory surgery record contains information most similar to _______________ operative records. - correct answer hospital
Which standardized tool is used to assess Medicare-certified rehabilitation facilities? - correct answer CAA (care area assessment)
Interdisciplinary care plans are an important part of which type of health record? - correct answer end stage renal disease [Show Less]