1. Your hospital is transitioning from paper-based records to electronic health records. Right now, part of

The record is paper, and some of it has been transitioned to electronic formats. AHIMA refers to this as a(n)
_______ Health record.

  1. source-oriented
  2. integrated
  3. problem-oriented
  4. hybrid
  5. Which of the following is required by the Joint Commission for ambulatory charts?
  6. Discharge summary
  7. Medication list
  8. Consent to treat
  9. Problem list
  10. You’re reviewing patient information in which resolution is a big factor. What system are you most likely

to be using?

  1. Pharmacy
  2. Biomedical
  3. Radiology
  4. Dictation/transcription
  5. Which of the following is an example of a secondary record?
  6. Demographic data
  7. Lab results
  8. SOAP note
  9. Billing claim
  10. In reverse chronological order, the _______ patient record is the most common record used.
  11. problem-oriented
  12. integrated
  13. hybrid
  14. source-oriented
  15. Admission and discharge notes are examples of
  16. demographic data.
  17. primary records.
  18. secondary records.
  19. claims.
  20. Which of the following is required by CMS?
  21. DEEDS
  22. UCDS
  23. OASIS
  24. NCDB
  25. You sit on the electronic health record committee that has decided to get systems that work best for each

department. This method is known as the _______ approach.

  1. best-of-breed
  2. integrated systems
  3. LOINC
  4. hanging protocol
  5. Which of the following requires that the criteria of message integrity, nonrepudiation, and user

authentication be used?

  1. Flow sheets
  2. Nomenclature
  3. EHR forms
  4. Electronic signatures
  5. Which of the following is an example of a secondary record?
  6. Dental record
  7. Ambulatory care record
  8. MPI
  9. Physician order
  10. Which of the following is required by the CMS?
  11. Refusal of treatment
  12. Advanced directive
  13. Medicare patient rights statement
  14. HIPAA consent
  15. Which of the following is used for planning care in an SNF?
  16. Data sets
  17. SOAP
  18. Case management
  19. RAI
  20. The nurse indicates that the patient in Room 302 is DNR. Where would you look to confirm this?
  21. Patient rights statement
  22. Advance directives
  23. Disclosure records
  24. Assignment of benefits
  25. The admission clerk misspells a patient’s name and therefore can’t find him in the system, so a new

number gets assigned and a chart created. This problem is a common downfall of

  1. electronic records.
  2. common names.
  3. paper records.
  4. unit numbering.
  5. Which of the following is considered a public health record?
  6. Medical history
  7. Organ donor
  8. Referral consult
  9. Death record
  10. Which of the following does AHIMA recommend keeping permanently?
  11. Death registry
  12. Mammography
  13. Children’s records
  14. Pathology reports
  15. You’re filing a patient’s paper record with the number 462-99-00. Your department is probably using

which filing system?

  1. Alphanumeric
  2. Straight numeric
  3. Family numbering
  4. Serial-unit
  5. Which of the following is often used to meet Joint Commission compliance?
  6. Unit numbering
  7. Serial-unit numbering
  8. Serial numbering
  9. Family numbering
  10. The downfall of this numbering system is that there may be multiple records for one patient.
  11. Family numbering
  12. Unit numbering

End of exam

  1. Serial-unit numbering
  2. Serial numbering
  3. You’re looking at a patient’s paper record in which all the physician notes are grouped together in one

section, the lab results are grouped together in another section, and the nursing notes are organized in yet
another section. Which type of record are you most likely viewing?

  1. Hybrid
  2. Integrated
  3. Source-oriented
  4. Problem-oriented

You might also order: