1. What is the primary purpose of a practice’s health record?
The primary purpose of a health record is to document care received, including the steps taken to identify a diagnosis or problem and to treat it.
2. What record purpose is associated with each of the following?
a. Medical assistant records the height, weight, and vital signs of a patient? Document care /services provided
b. The results of the effectiveness of a new drug involved in a clinical research trial are reported to the study coordinator? Communicate with other health care providers and/or provide data for public health and health policy
c. Penicillin is not prescribed for a patient because the allergy list indicates the patient will have a reaction to it? Provide support for clinical decisions
d. The results of an annual mammogram are reported to the primary physician. Communicate with other health care providers
3. In which record format would documentation of a nurse, physician, and therapist be found in chronological (date) sequence? Integrated record
4. Of the two major types of record data, which type includes the patient’s name, address, payment source, next of kin, treatment consents?
5. Which type of health record standard varies depending on the state in which the practice is located? Licensure standards
6. What type of health record standard is met when the practice is recognized as voluntarily meeting national indicators of quality care? Accreditation standards
7. Which organization was specifically formed to accredit only ambulatory care settings?
Accreditation Association for Ambulatory Health Care (AAAHC)
8. What nationally recognized ambulatory care data sets have an effect on record content?
Uniform Ambulatory Care Data Set ( UACDS).
9. What are five guidelines outlined by AHIMA for good documentation practices that support legal defense of a record?
Some of the AHIMA guidelines are as follows: