RHIT EXAM Health Data Content and Standards Flashcards

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is?

A. Recovery room

B. Pathology Report

C. Operative report

D. Discharge summary

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be?

A. Personal Identification

B. Cognitive patterns

C. Procedures and dates

D. Principal diagnosis

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the ?

A. prohibited use of any abbreviations

B. Flagrant use of specialty-Specific abbreviations

C. use of prohibited or "dangerous" abbreviations

D. use of abbreviations in the final diagnosis

Engaging patients and their families in health care decisions is one of the core objectives for

A. achieving meaningful use of EHRs

B. the Joint Commission's National Patient Safety goals

C. HIPAA 5010 regulations

D. establishing flexible clinical pathways

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the?

A. doctors progress notes

B. Integrated progress notes

C. incident report

D. Nurses notes

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the ?

A. Interdisciplinary patient care plan

B. Discharge Summary

C. transfer record

D. problem list

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that?

A. it is too easy to delegate use of computer passwords

B. Evidence cannot be provided that the physicians actually reviewed and approved each report

C. electronic signatures are not acceptable in every state

D. Tampering too often occurs with this method of authentication

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the ?

A. prenatal record

B. Labor and Delivery record

C. postpartum record

D. discharge summary

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. you tell Dr. Crossman?

A. a new H&P is required for every inpatient admission

B. that you apologize for not noticing the H&P she provided

C. the H&P copy is acceptable as long as she documents any interval changes

D. Joint Commission standards do not allow copies of any kind in the original records.

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's

A. disease index

B. Number Control index

C. Physicians index

D. Patient index

Joint Commission requires the attending physician to countersign health record documentation that is entered by:

A. interns or medical students

B. business associates

C. consulting physicians

D. Physician partners

The minimum length of time for retaining original medical records is primarily governed by

A. Joint Commission

B. Medical Staff

C. State Law

D. Readmission Rates

The use of personal signature stamps for authentication of entries in a paper based record reqires sepcial measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of

A. fingerprint signatures

B. voice recognition systems

C. expert systems

D. Electronic signatures

The first patient with cancer seen in your facility on January 1, 2012 was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is?

A. 13.0000/00

B. 13-000/01

C. 13-0001/00

D. 13-0001/01

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate

A. quality of care through the use of preestablished criteria

B. Adverse effects and contraindications of drugs utilized during hospitalization

C. Potentially compensable events

D. The overall quality of documentation in the record

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

A. Chief of Staff

B. Attending physician

C. HIM director

D. Risk Manager

The federally mandated resident assessment instrument used in long term care facilities consists of three basic components, including the new care area assessment, utilization guidelines and the

A. UHDDS

B. MDS

C. OASIS

D. DEEDS

The foundation for communicating all patient care goals in long-term care settings is the

A. legal assessment

B. medical history

C. Interdisciplinary plan of care

D. Uniform Hospital Discharge Data Set

As the Director of a Health Information Technology Program, your community college has been selected to participate in the workforce development of electronic health record specialists as outlined by ARRA and HITTECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency.

A. ONC

B. CMS

C. OSHA

D. CDC

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for

A. including the primary caregiver in surgery consults.

B. including the surgeon in the preanesthesia assessment

C. marking the surgical site

D. apprising the patient of all complications that might occur

In preparing your facility for initial accreditation by the Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of HIM department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards, your first recommended change is to

A. have more frequent committee meetings

B. have committee report to the Executive Committee

C. have a physician perform all the reviews

D. provide for record reviews to be performed by an interdisciplinary team of care providers.

According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations would most likely be prohibited?

A. 0.4 mg Lasix

B. 4 mg Lasix

C. 40 mg Lasix

D. .4 mg Lasix

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1 . Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P (History & Physical examination) indicates?

A. noncompliance with Joint Commission standards

B. compliance with Joint Commission standards.

C. compliance with Medicare regulations.

D. compliance with Joint Commission standards for nonsurgical patients.

The use of personal signature stamps for authentication of entries in a paper based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of

A. fingerprint signatures

B. voice recognition systems

C. expert systems

D. Electronic signatures

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?

A. disease index

B. physician index

C. master patient index

D. operation index

The best example of point-of-care service and documentation is

A. using an automated tracking system to locate a record

B. using occurrence screens to identify adverse events

C. doctors using voice recognition systems to dictate radiology reports

D. nurses using bedside terminal to record vital signs.

Many of the principles of forms design apply to both paper-based and computer based systems. For example, the physical layout of the form and / or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to

A. placement of hospital logo

B. signature line for authentication

C. use of box design

D. bar code placement

Which of the following is a form or view that is typically seen in the health record of a long term care patient but is rarely seen in records of acute care patients?

A. pharmacy consultation

B. medical consultation

C. physical exam

D. emergency record

The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case?

A. data comprehensiveness

B. data granularity

C. data precision

D. data accuracy

The first patient with cancer ween in your facility on January 1, 2012 was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is?

A. 13.0000/00

B. 13-000/01

C. 13-0001/00

D. 13-0001/01

Setting up a drop down menu to make sure that the registration clerk collects "gender" as "male", female, or unknown" is an example of ensuring data.

A. reliability

B. timeliness.

C. precision

D. validity

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

A. CARF manual

B. hospital bylaws

C. Joint Commission accreditation manual

D. Federal Register

In an acute care hospital, a complete history and physical may not be required for a new admission when

A. the patient is readmitted for a similar problem within 1 year

B. the patient's stay is less than 24 hours.

C. the patient has an uneventful course in the hospital

D. a legible copy of a recent H&P performed in the attending physician's office is available.

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

A. Minimum Data Set

B. Uniform Hospital Discharge Data Set

C. Conditions of Participation

D. Federal Register

Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's

A. EDMS systems

B. CPOE

C. expert system

D. RHIO

When developing a data collection system, the most effective approach first considers

A. the end user's needs

B. applicable accreditation standards

C. hardware requirements.

D. facility preference

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the

A. physical findings

B. lab and diagnostic test results

C. time and means of arrival

D. instructions for follow up care

A data item to include on a qualitative review checklist of infant and children inpatient health records that need not be included on adult records would be

A. chief complaint

B. condition on discharge

C. time and means of arrival

D. growth and development record

You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the time line for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and will end 2014. You remind him that by 2015, sanctions for noncompliance will appear in the form of

A. downward adjustments to Medicare reimbursement

B. the withdrawal of permission to treat Medicare and Medicaid patients

C. a mandatory action plan for implementing a meaningful use EHR

D. monetary fines up to $100,000

In creating a new form or computer view, the designer should be most driven by

A. QIO standards

B. medical staff bylaws

C. needs of the users

D. flow of data on the page or screen

Under which of the following conditions can an original paper based patient health record be physically removed from the hospital?

A. when the patient is brought to the hospital emergency department following a motor vehicle accident and, after assessment, is transferred with his health record to a trauma designated emergency department at another hospital

B. when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court

C. when the patient is discharged by the physician and at the time of discharge is transported to a long term care facility with his health record

D. when the record is taken to a physician's private office for a follow-up patient visit postdischarge

According to the following table, the most serious record delinquency problem occurred in which of the following months?

A. April

B. May

C. June

D. cannot determine from these data

Using the SOAP style of documenting progress notes, choose the "subjective statement from the following?

A. Sciatica unimproved with hot pack therapy

B. patient moving about very cautiously, appears to be in pain

C. adjust paint medication; begin physical therapy tomorrow

D. patient states low back pain is as severe as it was on admission

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the

A. UHDDS

B. MDS

C. Uniform Clinical Data Set

D. Uniform Ambulatory Core Data

As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the

A. facility's data dictionary

B MDS

C. glossary of health care terms

D. UHDDS

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate the due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)____________ will be added to his health record.

A. interval summary

B. consultation reports

C. advance directive

D. interdisciplinary care plan

An example of objective entry in the health record supplied by a health care practitioner is the

A. past medical history

B. physical assessment

C. chief complaint

D. review of systems

You have been appointed as Chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medial staff bylaws, rules and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at

A. 12 hours after admission

B. 24 hours after admission

C. 12 hours after admission or prior to surgery

D 24 hours after admission or prior to surgery

Based on the following documentation in an acute care record, where would you expect this excerpt to appear?

A. physician progress notes

B. operative record

C. nursing progress notes

D. physical examination

A surgeon on the Health Record Committee voices a concern that, although he has told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog, which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should

A. provide the dictated tape to his staff

B. request a "stat" report

C. write a detailed operative note in the record

D. request that administration hire more transcriptionists

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

A. Yes, within 8 hours post surgery

B. No, as long as it is done ASAP

C. Yes, prior to surgery

D. Yes, within 24 hours post surgery

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

A. quantitative record review

B. clinical pertinence review

C. concurrent record analysis

D. point-of-care documeentation

An example of a primary data source for health care statistics is the

A. disease index

B. accession register

C. MPI

D. hospital census

In the computerization of forms, good screen view design, along with the options of alerts and alrams, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on teh physical exam is the

A. general appearance as assessed by the physician

B. chief complaint

C. family history as realted by the patient

D. subjective review of systems

Which of the following is least likely to be identified by a deficiency analysis technician?

A. missing discharge summary

B. need for physician authentication of two verbal orders

C. discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist

D. x-ray report charted on the wrong record

The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation?

A. tissue examination done by the pathologist

B. impressions of a cardiologist asked to determine whether patient is a good surgical risk

C. interpretation of a radiologic study

D. technical interpretation of electrocardiogram

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

A. utilization review

B. quantitative review

C. legal review

D. qualitative review

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding.

A. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings and specimens removed

B. whether a postoperative infection occurred and how it was treated

C. the quality of follow up care

D. whether the severity of illness and /or intensity of service warranted acute level care

In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from

A. generic screens used by record abstractors

B. disease index

C. R-ADT system

D. indicator monitoring program

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing.

A integrated progress notes

B. interdisciplinary treatment plans

C. source oriented records

D. SOAP notes

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

A. chronic pain management

B. palliative care

C. brain injury management

D. vocational evaluation

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record?

A. written signature of the provider of care

B. identifiable initials of a nurse writing a nursing note

C. a unique identification code entered by the person making the report

D. delegated use of computer key by radiology secretary

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a

A. data warehouse

B. regional health information organization

C. continuum of care

D. data retrieval portal group

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?

A. DEEDS

B. UHDDS

C. MDS

D. ORYX

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the

A. Consolidated Manual for Hospitals

B. Federal Register

C. Policy and Procedure Manual

D. hospital Bylaws, Rules, and Regulations

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of

A. peer review

B. quantitative review

C. qualitative review

D. legal analysis

Accreditation by Joint Commission is a voluntary activity for a facility and it is

A. considered unnecessary by most health care facilities

B. required for state licensure in all states

C. conducted in each facility annually

D. required for reimbursement of certain patient groups

Which of the following indices might e protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff?

A. disease index

B. procedure index

C. master patient index

D. physician index

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?

A. database

B. problem list

C. initial plan

D. progress notes

As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use

A. patient abstracts

B. patient index

C. accession register

D. follow-up files

As the Compliance Officer for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling.

A. EMTALA

B. Health Care Quality Improvement Act

C. HIPAA

D. ARRA

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record

A. Patient admitted with COPD 1/4/2013 and discharged 1/7/2013

B. Baby Boy Hiltz, born 1/5/2013, maintained normal status, discharged 1/7/2013

C. Baby Boy Hiltz's mother admitted 1/5/2013, C-section delivery, and discharged 1/7/2013

D. Baby Boy Doe admitted 1/3/2013, died 1/4/2013

Based on the following documentation in an acute care record, where would you expect this excerpt to appear?

"Initially the patient was admitted to the medical unit to evaluate the x-ray findings and t he rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient"

A. discharge summary

B. physical exam

C. admission note

D. clinical laboratory report

The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the

A. Conditions of Participation for Rehabilitation Facilities

B. Medical Staff Bylaws, Rules, and Regulations

C. Joint Commission manual

D. CARF manual

Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage?

A. Use CPOE for medication orders

B. Smoking cessation counseling for MI patients

C. Appropriate use of HL-7 standards

D. Establish critical pathways for complex, high dollar cases

Which of the following is secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

A. disease index

B. patient register

C. pediatric census sheet

D. procedure index

As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting over payments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with

A. the OIG

B. MEDPAR representatives

C. QIO physicians

D. recovery audit contractors

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data

A. timeliness

B. accuracy

C. comprehensiveness

D. security

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the mot serious pattern of delinquencies? Fifteen percent of delinquent records show

A. missing signatures on progress notes

B. missing discharge summaries

C. absence of SOAP format in progress notes

D. missing operative reports

A primary focus of screen format design in a health record computer application should be to ensure that

A. programmers develop standard screen formats for all hospitals.

B. the user is capturing essential data elements

C. paper forms are easily converted to computer forms

D. data fields can be randomly accessed.

A quality improvement team is focusing on the unacceptable number of unsigned doctors orders in your facility. The most effective method for increasing the timeliness of signatures on orders and positively impacting the patient care process would be

A. performing a retrospective review where all orders can be flagged at one time

B. holding a printed order sheet on the medical care unit at least 24 hours post-discharge to give the physician time to sign

C. developing an open record review process

D. devising a signature sheet for the attending physician to sign prospectively that will apply to all orders given during the current episode of his patient's care

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the

A. peer review organization

B. national Practitioner Data Bank

C. risk manager

D. Health Plan Employer Data and Information Set

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data

A. reliability

B. accessibility

C. legibility

D. completeness

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition verbal orders must be

A. written within 24 hours of the patient's admission

B. accepted by charge nurses only

C. cosigned by the attending physician within 4 hours of giving the order

D. recorded by persons authorized by hospital regulations and procedures

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave

A. documented in an incident report and filed in the patient's health record

B. reported as a potentially compensable event

C. reported to the Executive Committee

D. documented in both the progress notes and the discharge summary

Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every

A. week

B. month

C. 60 days

D. 90 days

You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be

A. medical staff bylaws

B. quality management plan

C. Joint Commission accreditation manual

D. medical staff rules and regulations

A quarterly review reveals the following data for Springfield Hospital

What is the percentage of incomplete records during this quarter?

A. 55%

B. 54%

C. 33%

D. 32%

Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital.

A. 55%

B. 32%

C. 33%

D. 54%

Still referring to the information in the table in question 88 and the delinquent record rate shown in the answers for question 89, would the facility by out of compliance with Joint Commission standards?

A. yes

B. no

In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the

A. Information security manager

B. Clinical data specialist

C. Health Information manager

D. Risk Manager

For inpatients, the first data item collected of a clinical nature is usually

A. principal diagnosis

B. expected payer

C. admitting diagnosis

D. review of systems

Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is

A. beta blocker at discharge

B. blood culture before first antibiotic received

C. early administration of aspirin

D. discharged on antithrombotic

One record documentation requirement shared by Both acute care and emergency department is

A. patient's condition on discharge

B. time and means of arrival

C. advance directive

D. problem list

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

A. standing orders

B. telephone orders

C. stop orders

D. discharge order

As the chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document

A. objective symptoms observed by the physician

B. past and current activities, such as smoking and drinking habits

C. a chronological description of patient's present condition from time of onset to present

D. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets

A. Joint Commission standards

B. NHIN standards

C. HL-7 standards

D. CMS standards

Based on the following documentation in an acute care record, where would you expect this excerpt to appear?

"The patient is alert and in no acute distress. Initail vital signs: T98, P102 and regualr, R20 and BP 120/69....."

A. physical exam

B. past medical history

C. social history

D. chief complaint