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WorksheetsChapter 4 quiz
Total questions: 15
Worksheet time: 8mins
What does SOMR stand for?
source-oriented medical record
summary oriented medical record
source official medicine report
senior oriented medication record
What is an electronic signature ?
An electronic image of a handwritten image
A code of letters, numbers, & characters, similar to a PIN
A computer generated signature code
All of them above
How are two ways SOMR can be organized ?
Category & by source
Problem list
NCQA
Summary
When you organize a record or information by category this includes..
Progress notes
discharge summary
practitioner documentation
All of them above
What does POMR not include
The diagnostic plan
The therapeutic plan
The educational plan
Discharge summary
What does HERO stand for
Early Health Related Organization
Electronic History Record Organization
Electronic Health Record Organization
External Health Record Organization
A discharge summary is
A series of summary notes made by the providers of care
A set of educational materials provided to the patient upon discharge
Part of the patient’s bill, used to substantiate care provided
A summary of the patient’s stay from admission to discharge
A problem list is
A document providing dates and conditions for all visits
A POMR
A tool to manage information
Clinical documentation
What format are SOAP notes in?
A format for organizing information documented in the record
A format for the patient's medical problems identified in the medical history and physical examination
A format of organized documents from the PATIENT'S record
It doesn't have a format
The goal of clinical documentation improvement is ____
to ensure all patient information is created maintained electronically
to have patient information that is complete, legible, timely, concise, clear, patient-centered, and accurate.
to decrease the number of incomplete and delinquent patient records
All the choices are correct.
Whats a pathology report?
A detailed report of the findings from the analysis of specimens removed during surgery
A fake report
A narrative description of the surgical procedure, beginning with the type of and the location of the incision made and including an exact description of the procedure
A record of the patient's condition during recovery from anesthesia until the patient is returned to his or her hospital room or discharged.
What does the NB (new born) patient record include?
Portions of the mothers OB record, including the pental record
Observation after birth, delivery room care, and a physical exam
Log and flow sheets recording temperature, weight, urination, and stool
A PKU report documenting the results of metabolic-disease screening tests, and the name of the person to whom the NB is released
All of the above
What is clinical documentation?
The capture and the recording of clinical information.
Used in making patient care decisions includes the patient’s medical history and physical exam,labs,and X-rays along with evaluations by the practitioner(s).
A program to improve the quality of documentation to ensure that it is complete,legible,timely, concise,clear,patient-centered, and accurate
What even is this
Medicare CoPs specify that if a record is in incomplete after 30 days, its is considered….
Information governance
Delinquent record
Incomplete record
What is a recovery room report?
Narrative description of the surgical procedure, beginning with the type of and the location of the incision made and including an exact description of the procedure
Record the patient’s condition during recovery from anesthesia until the patient is returned to his or her hospital room or discharged
Detailed report of the findings from the analysis of specimens removed during surgery
There is no such thing as a “recovery room report”
