Introduction to the Health Record Jeopardy Introduction to the Health Record

Record Order Accrediting Bodies Types of Data Data Collection 100 100 100 100 200 200 200 200 300 300 300 300 400 400 400 400 500 500 500 500

Records are organized by date, What is Integrated? Records are organized by date, chronologically. Row 1, Col 1

Accredits acute care facilities. What is The Joint Commission on Accreditation of Healthcare Organizations? Accredits acute care facilities. (JCAHO) 1,2

The type of data that includes the patient’s insurance company What is Financial? The type of data that includes the patient’s insurance company and policy number. 1,3

Data obtained through examination and study. What is Objective? Data obtained through examination and study. 1,4

Data is organized by diagnosis. What is Problem-Oriented? Data is organized by diagnosis. 2,1

Accredits home health care What is the Community Health Accreditation Program? Accredits home health care organizations. (CHAP) 2,2

What are examples of Socioeconomic data? Marital Status Education Race/Ethnicity Personal Habits 2,3

The description of the concern in the patient’s own words. What is Subjective? The description of the concern in the patient’s own words. 2,4

All labs results are filed What is Source-Oriented? All labs results are filed under one tab. 3,1

Accredits managed care What is the National Committee for Quality Assurance? Accredits managed care organizations. (NCQA) 3,2

Information to confirm the identity of the patient. What is Demographic data? Information to confirm the identity of the patient. 3,3

Take ibuprofen as needed for pain. What is a Plan? Take ibuprofen as needed for pain. 3,4

patient’s appendicitis is together, hypertension is together… What is Problem -Oriented? All the information about the patient’s appendicitis is together, all information about hypertension is together… 4,1

What is the Accreditation Association for Ambulatory Health Care? Accredits ambulatory care facilities. (AAAHC) 4,2

What are examples of Clinical data? Temperature Blood Pressure Medications 4,3

physician’s assessment. What is diagnosis? Another term for the physician’s assessment. 4,4

of chronic diseases is easier. What is Problem-Oriented? Long-term management of chronic diseases is easier. 5,1

Accredits rehabilitation What is the Commission on Accreditation of Rehabilitation Facilities? Accredits rehabilitation facilities. (CARF) 5,2

which provides meaning. What is information? Data organized in a way which provides meaning. 5,3

Logical way in which health to make medical decisions What is SOAP Format? Logical way in which health data is organized to make medical decisions about a patient. 5,4