1.  A Medical Record may be used for:

    A.  Data for research

    B.  To collect reimbursement

    C.  To manage diagnostic and patient treatment

    D.  All of the above

2.  Which of the following is Not part of the Medical Record?

    A.  The Physician Progress Note

    B.   Nurse’s Progress Note

    C.  Intake and Output Record

    D.  The Medical Record contains all of the above

3.  A patient’s “Face Sheet” may contain which of the following ?

    A.  Social Security Number

    B.  Driver’s License Number.

    C.  Bank Account Number

    D.  None of the above 

4.  Elements of Good Documentation include which of the following?                                                          

    A.  Write legibly and neatly

    B.  Be factual and descriptive

    C.  Do not leave any blank spaces before you signature on a chart

    D.  Should perform all of the above

5. Medical Records are legal documents, whether in hard copy form or computer-generated.  Patient data is:

    A.  Failing to record that medications have been given

    B.  Failing to record changes in the patient’s condition

    C.  Failing to record adverse incidents that happen to the patient

    D.  All are common charting errors

6. When an error has been made…

    A.  Erase the lines as clean as possible

    B.  Write over or obliterate any entries in the chart. your protection.

    C.  When incorrect information is written, draw a single line through the entry, date it, initial it, and then enter the correct information

    D.  You must neatly and clearly “White Out” all of your errors

7. You can prevent medical errors by documenting defensively.  (Please circle the letter in front of each statement that provides correct information in regards to documenting):

    A.  Cannot be modified at all

    B.  Should be left alone if nobody is aware but you

    C.  May result in a non-payment of a claim

    D.  Can be any of the above

8. If the patient is supposed to be taken off a medication, what must you do?

    A.  You need to document that order promptly in the patient’s record

    B.  You need to tell everyone working with the patient so everyone knows

    C.  Must notify the patient’s family immediately by phone

    D.  Must do all of the above

9. What documentation must not be documented in the Medical Record?

    A.  Errors that occur such as a medication error

    B.  Medical device malfunctions

    C.  A staff member or visitor is injured.

    D.  All of the above should not be documented in the Medical Record

10.  To assure proper payment for the services rendered, what must be in place?

    A.   The Patient must sign over “Power of Attorney” to facility in order to accurately bill for services

    B.   Proper documentation justifying the care given must be clearly provided in the Medical Record

    C.  The patient must surrender their personal insurance documentationd.

    D.  None of the Above

11. Describe Narrative Charting

    A.  Consists of  speaking into a cassette and recording your charting audibly

    B.  Consists of a straight forward written account of the patient’s status, the nursing interventions performed, and the patient’s true response to those interventions

    C.  Consists of verbally telling the oncoming personnel everything that happened during the shift to the patient

    D.  None of the above

12. The “SOAP” Method of charting is what type of charting?

    A.  Problem Oriented Charting

    B.  Focus Charting

    C.  Narrative Charting

    D.  Charting by Exception

13. What is the name of the law that protects the confidentiality of Medical Record and the health information within the record?

    A.  The Privacy Act of 1992

    B.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

    C.  The Bill of Human Rights 1776

    D.  None of the Above

14.  What patient’s rights does a “Notice of Privacy” outline ?

            A.  The right to access their own medical records

            B.  The right to amend their record if contains errors

            C.  The right to confidential communication

            D.  All of the Above

15.  Which of the following is Not part of the Medical Record?

    A.  The Medical Record belongs to the patient and if he request can possess the Medical record and take the chart home

    B.   Patients do have the right to view their medical records, although specific arrangements are usually made available to the patient when viewing the medical record

    C.  The patient is never allowed to view the chart or have copies

    D.  None of the Above

16.  A patient’s “Face Sheet” may contain which of the following ?

    A.    Documentation that shows the patient has been informed of their “Rights” including the OASIS Privacy Notice about Advance Directives

    B.  A Plan of Care (POC) must be implemented describing the treatments and services that are to be provided

    C.   Clinical Notes must be completed by the healthcare Provider rendering the  care and that physicians were notified when changes in the patient status occurs.

    D.  All of the above is required for Medicare Reimbursement 

17.  If a patient refuses recommended treatment or is noncompliant?

    A.  That is OK because that is a patient’s right

    B.   Document that the patient was informed of the risks by not consenting and document his/her refusal and the notify your Nurse-Manager

    C.  Contact the patients family to convince treatment is the right thing to do Do not leave any blank spaces before you signature on a chart

    D.  None of the above is true  

18. How can the patient expect a quality outcome?

    A.  By proper documentation by all of the healthcare team

    B.   Continued improvement in documentation

    C.  Always document as if your documentation was being read in court

    D.  All the above

19. How can the patient expect a quality outcome?

    A.  By proper documentation by all of the healthcare team

    B.   Continued improvement in documentation

    C.  Always document as if your documentation was being read in court

    D.  All the above

20.  When documenting notes in a patient’s chart:

    A.   Don’t worry if no one can read your writing, only you need to know what you wrote

    B.  Use as many abbreviations as possible as it saves time and paper

    C.  Don’t worry if you forget to sign your name and your title, everyone knows your writing and your supervisor knows what days you worked

    D.  None of the above

 


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Copyright © 2003 [Infusion Inc.]. All rights reserved.
Revised: 02/25/14.