Documentation & Health Records Flashcards

Before admission paperwork is complete, what should the HUC check about every form placed in a new patient's chart?

Answer: That each page has the patient's identification label or imprint

Every chart form needs patient ID so documents are never misfiled or credited to the wrong patient.

In computerized provider order entry (CPOE), who usually enters medication orders directly into the system?

Answer: The physician or authorized provider

CPOE has providers enter orders themselves, which cuts down on transcription errors.

A HUC notices a physician's handwritten order is unclear. What is the correct action?

Answer: Have the nurse or physician clarify the order before transcribing it

Unclear orders must be clarified with the nurse or prescriber to prevent errors.

Which form documents that a patient understands the risks, benefits, and alternatives of a surgical procedure?

Answer: Informed consent form

Informed consent is signed after the physician explains the procedure's risks, benefits, and alternatives.

Which chart form usually holds patient demographics, insurance information, and emergency contacts?

Answer: Face sheet

The face sheet (admission sheet) summarizes demographic and insurance data.

Under HIPAA, the 'minimum necessary' standard means:

Answer: Only the minimum amount of PHI needed for a task should be used or disclosed

Workers should access and share only the PHI their job function needs.

After transcribing a set of physician orders, how does the HUC show the orders were processed?

Answer: Signs off with name, title, date, and time as facility policy requires

Signing off with name, title, date, and time shows who transcribed the orders and when.