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Essential medical record components include:

a. Documentation and findings of assessments

b. Diagnostic procedures, tests and results

c. Reports of adverse events/incidents

d. Subjective comments

e. Medications ordered and administered

Group of answer choices

a, b, e

a, b, c

a, c, d

b, d, e

all of the above

EMTALA compliance involves a variety of mandates: Which one of the following is not one of them:

a. Provide a clinical assessment to determine if an individual presenting at a dedicated emergency department has an emergency medical

condition.

b. Efforts must be made to stabilize any identified emergency medical condition of such patients.

c. Determine whether these patients are Medicare-eligible.

d. Transfer un-stabilized patients to a higher level of care if the treating hospital doesnt have the resources to care for them

Group of answer choices

c

a

b

d

Plaintiff attorneys look for the following in the medical record:

a. Alterations

b. Vague, ambiguous or contradictory statements

c. Objective description of observations

d. Patient compliments and thank you letters

e. Gaps in documentation

Group of answer choices

a, b, e

a, b, c

b. c, d

c, d, e

all of the above

In a hard copy/paper medical record, the biggest documentation challenge is?

a. Legibility

b. Non-approved abbreviations

c. Alterations

d. Subjective comments

Group of answer choices

a

d

b

c

all of the above.

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