Which of the following materials is not documented in an emergency care record?
26 Cards in this SetChapter 3Content and Structure of the Health RecordWhich of the following materials is not documented in an emergency care record?patient's instructions at dischargeWhich of the following types of facility is not governed by Medicare long-term care documentation standards?assisted living facilities23 more rows
What are the two major types of documentation in a health record?
The health record generally contains two types of data: clinical and administrative. Clinical data document the patient's medical condition, diagnosis, and treatment as well as the healthcare services provided.
Who determines who can receive and transcribe verbal orders?
Health Information ManagementQuestionAnswerWhich type of specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?Emergency care recordWhich of the following determines who can receive and transcribe verbal orders?Medical staff bylaws23 more rows
Which of the following forms of information are considered clinical information?
For example, clinical information includes the services provided, medications or tests ordered, type of report, and location of care. can be divided into administrative, demographic, and financial information. Most hospitals still use paper-based forms to some extent.
What types of records are not able to be accessed by the patient?
In addition, two categories of information are expressly excluded from the right of access: Psychotherapy notes, which are the personal notes of a mental health care provider documenting or analyzing the contents of a counseling session, that are maintained separate from the rest of the patient's medical record.
What are the 3 types of medical records?
There are three types of medical records commonly used by patients and doctors:Personal health record (PHR)Electronic medical record (EMR)Electronic health record (EHR)
Which type of information is not maintained in a medical record?
Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney, Unprofessional or personal comments about the patient, or.
Which of the following principles support proper information governance?
The principles of retention, availability, and disposition are all important in supporting proper information governance across the organization. The principle of interoperability is more limited to the IT Department.
Which of the following is an organization that develops standards related to healthcare delivery?
An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care.
Which of the following is someone non clinical that documents the patient's evaluation?
Scribe: documents the patients visit on behalf of the physician. What is the scope of a scribe? An unlicensed person performing documentation and other non-clinical tasks under the direction of a healthcare provider.
Which of the following are components necessary for proper documentation in a patients medical chart?
What Are The 10 Components Of A Medical Record?Identification Information. One of the first important components you can find in medical records is the identification information. ... Medical History. ... Medication Information. ... Family History. ... Treatment History. ... Medical Directives. ... Lab results. ... Consent Forms.More items...•
What are the different types of medical documents?
What is a medical document?PIL. A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy. ... Medical history record. ... Discharge Summary. ... Medical test. ... Mental Status Examination. ... Operative Report.