Term
| What is the Short-term medical and nursing care provided by inpatient hospital setting to treat the acute phase of a patient’s s injury or illness |
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Term
| What is the term for health records maintained by patients and/or their families? |
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| _____, health records are the property of the healthcare providers who create them;________ the personal information contained in each record belongs to the patient |
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Term
| Each organization must define the parameters of its legal health records, taking into account_____________. |
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Term
| Copies of personal health records (PHRs) are consider part of the legal health record when____________? |
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Definition
| Used by the organization to provide treatment |
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Term
| A _____ is a health record that include all of the health-related information generated for an individual during his/her lifetime. |
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Definition
| Longitudinal health records |
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Term
| What factor is medical necessity based on? |
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Definition
| The beneficial effects of a service on patient’s physical need of quality of life. |
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Term
| Before a hospital is permitted to provide medical services in a particular state, the organization must go through what process? |
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Term
| What is the principle function of a health records? |
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Definition
| To serve as the repository of clinical documentation relevant to the care of individual patients. |
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Term
| What type of data are consents and authorization? |
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Term
| A rule established by the administrative agency of government? |
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Definition
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Term
| What category of services applies to tests related to cardiac and neurological functioning? |
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Definition
| Specialty diagnostic services |
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Term
| What is the voluntary, systematic quality review process that evaluates the healthcare facility's performance against pre-established, written criteria? |
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Term
| The mandatory process whereby state governments grant individual hospitals permission to operate within a specific geopolitical area is? |
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Definition
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Term
| What is the purpose of clinical pathways? |
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Definition
| To reduce costs and improve quality through decreased variation in practices. |
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Term
| According to accreditation standards, which document must be placed in the patient's record before a surgical procedure may be performed? |
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Definition
| Report of history and physical examination. |
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Term
| A(n) _________________ is a multidisciplinary tool for organizing the diagnostic and therapeutic services to be provided to the patient? |
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Definition
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Term
| When a patient collapses upon arrival at the entrance to an emergency department, what type of treatment authorization is in effect? |
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Term
| In what of the following types of health record documentation would you find statements like this one: "Specimen consists of normal fallopian tubes and ovaries and uterus showing submucusleiomyomas"? |
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Definition
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Term
| "100 mg of penicillin per mouth administered at 8 a.m." is an example of what kind of documentation? |
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Definition
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Term
| Under which circumstances may an interval note be added to a patient's health record in place of a complete history and physical? |
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Definition
| When the patient is readmitted within thirty days of the initial treatment for the same condition. |
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Term
| What type of term is used in reference to a written document that describes the patient's healthcare preferences in the event he or she becomes unable to communicate directly in the future? |
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Term
| Type of physician documentation is used to document the patient's own description of his or her present illness? |
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