Questions 1–15

1. Which piece of information should the staff enter in the administrative data category in the portal?

• The patient’s diagnostic orders

• The patient’s chief complaint

• The patient’s date of birth

• The patient’s medical history

2. Which piece of information should the patient enter in the administrative data category in the portal?

• The patient’s weight

• The patient’s social history

• The patient’s name

• The patient’s past medical history

3. A patient admitted to the hospital had a resection of the right lower lobe. When should the operative report be completed?

• Within 15 days of surgery

• Immediately after surgery

• Within 48 hours of surgery

• Within 24 hours of surgery

4. Which document is used in an acute care setting but not an ambulatory care setting?

• Physical examination

• Advance directive

• Discharge summary

• Do-not-resuscitate order

5. What is the time frame required for completing the physical examination by the practitioner?

• No more than 24 hours after admission

• No more than 72 hours after admission

• No more than 8 hours after admission

• No more than 48 hours after admission

6. What is the medical record format that combines both paper-based and electronic forms to accommodate the several ways in which patient information is gathered and stored?

• A source-oriented record

• An integrated record

• A hybrid record

• A longitudinal record

7. What is the disadvantage of maintaining paper-based medical records?

• Paper-based medical records allow clinicians to access the records simultaneously, which can increase the chances for error.

• Paper-based medical records can be maintained at multiple locations, which can affect the integrity of the records.

• Paper-based medical records can be accessed by one person at a time, which causes a delay in information processing.

• Paper-based medical records can be accessed by multiple people, which can jeopardize patient privacy.

8. A cardiologist recommended a change to a patient’s cardiac pacemaker and would like to monitor the function of the new pacemaker after discharge. Which technology specifically supports patient-centered care for this patient?

• Health information exchange (HIE)

• Physiological signal processing systems

• Patient portal

• Electronic health record (EHR)

9. Which component of the medical history consists of questions to cue the patient to reveal symptoms that the patient may have forgotten or overlooked?

• Past medical history

• Review of systems

• Social and personal history

• History of present illness

10. Which statement accurately describes the process of giving and receiving verbal orders?

• Verbal orders are signed by the patient receiving the orders.

• Verbal orders for medication can be given to anyone who is attending to the patient.

• The person accepting verbal orders should record the orders, read them back to the ordering physician, sign them, and give their title.

• The Joint Commission requires that the documentation of verbal orders include just the names of individuals who gave and received the orders.

11. Which component within a medical record consists of information about a patient’s marital status?

• The discharge summary section

• The medical history section

• The nursing services section

• The clinical observations section

12. Which component within a medical record consists of a patient’s anesthesia records?

• The surgical services section

• The history and physical section

• The demographic data section

• The ancillary services section

13. Where should the provider document the patient’s care, treatment, and therapeutic responses in the health record?

• History and physical

• Consultation reports

• Progress notes

• Discharge summary

14. What is the purpose of the computerized physician order entry (CPOE) in an acute care facility?

• It helps to substantiate reimbursement.

• It helps to communicate physician’s orders.

• It helps with planning and development.

• It helps physicians to reconcile medications.

15. What is the function of diagnostic/therapeutic orders?

• They chronologically document responses to treatment.

• They direct the healthcare team.

• They document the opinions of specialty physicians.

• They are subjective summaries of patient illnesses.

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