Healthcare Delivery
Clinical Documentation & Health Record
Functions of the Record
Documentation for Statistics
Clinical Information
100

What type of care provides Surgical Services that do not require overnight Hospitalizations?

Ambulatory Care

100

ROI

Release of Information 

100

Represents objective descriptions of process,procedures,people,, and other,observable things and activities.

Data

100

This database is an integrated information and communication system for health

WONDER

100

Name, address,age,consents,financial data

Administrative Information

200
What is another name for behavioral health?

Psychiatric care

200
The patient owns the health record

False

200

Analysis of data for a specific purpose 

Information 

200

NCHS

National Center for Health Statistics

200

Medical history,diagnostic/therapeutic orders,observation 

Clinical information

300
What care is provided in a patients residence?
Home care
300

Disclosure of patients information or the the process that makes health record information available to legitimate users

Release of information

300

PI

Performance Improvement

300

Data included in Vital Statistics

Births,death,fetal death,marriage and divorce

300

Chronological record of the clinical observations of the patients conditions and response to treatment during the hospital stay

Progress notes

400

What part of the continuum of care is highly specialized and technologically advanced diagnostic and therapeutic services?

Tertiary Care

400

Destruction of records can be done whenever is necessary 

False
400

The main purpose of Risk Management is the prevention of situation that might out the hospital,patients,caregiver,or visitors, in danger.

True

400

Which index provides access to multiple repositories of information from overlapping patient population that are maintaining in-separate systems and databases

Enterprise Master Patient Index

400

One physician seeks the advice of another physician before making decisions about about diagnostic and treatment

Consultation 

500

PHR

Personal Health Record

500

Official business record used for evidentiary purposes created by or for the health care organization

Legal Health Record

500
QIO

Quality Improvement Organizations

500

NPDB

National Practitioner Data Bank

500
Condition established after study, to have been the main reasons for the patients admission to the hospital

Principal diagnosis