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Health Record and Patient Record Purposes

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Health Record and Patient Record Purposes

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Questions and Answers

What is one of the purposes of the health record assessment?

To facilitate reimbursement decisions

To compare objective and subjective assessment data (correct)

To conduct medical record audits for quality assurance

To provide a legal document for court use

How does the patient record serve the purpose of quality assurance?

By allowing comparison of objective and subjective assessment data

By facilitating reimbursement decisions

By enabling medical record audits to determine standards of care (correct)

By providing a legal document for court use

What is a significant aspect of the patient record with regards to reimbursement?

Providing the basis for decisions regarding care and subsequent reimbursement (correct)

Facilitating medical research

Allowing comparison of assessment data

Serving as a legal document for court use

How does accurate documentation in patient records contribute to research?

By ensuring that research outcomes are valid and reliable Signup and view all the answers

What is the primary purpose of maintaining confidentiality in nursing documentation?

To protect the patient's privacy and comply with legal and ethical requirements Signup and view all the answers

Why should students de-identify any patient information in written assignments?

To ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) Signup and view all the answers

What is the main guideline for nursing documentation to maintain accuracy?

Proofreading to ensure correct spelling and use of medical terms Signup and view all the answers

Why should direct quotes of patient statements be used in nursing documentation?

To maintain objectivity, especially when documenting psychosocial and mental health issues Signup and view all the answers

What is the significance of documenting information chronologically?

It ensures that important information is not forgotten Signup and view all the answers

Why should only commonly accepted and approved abbreviations be used in nursing documentation?

To ensure that all healthcare professionals understand the abbreviations Signup and view all the answers

Why is the standardized vocabulary important in the electronic health record?

To facilitate the retrieval of individual and aggregate data Signup and view all the answers

What is the goal of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act?

To increase patients’ access to their own medical records Signup and view all the answers

What do clinical surveillance tools do in relation to electronic health record data?

They produce real-time patient risk scores for designated high-risk conditions Signup and view all the answers

What does the Universal Computer-Based Patient Record aim to achieve?

Increase patients’ access to their own medical records Signup and view all the answers