Download Answer Key - Worksheets - Content of the Patient Records

Chapter 5 – Answer Key – Worksheets
Face Sheet, Patient Assessment & Reassessment, History, Physical
Examination, Admission/Discharge Record
Admission/Discharge Record
1.
“Face Sheet” is also known as:
Clinical, Demographic, and
Financial
2.
The face sheet contains three types of information. Name
them.
Patient Name, Address,
Phone Number, etc.
Insurance Company Name,
Policy Number, etc.
3.
Identify 4 common data elements collected on the face sheet.
History
4.
The chief complaint is documented on the:
Provisional Diagnosis
5.
The physician uses the above to establish the _____
diagnosis.
Review of Systems
6.
The physician's assessment of all body systems is called the:
30 days
7.
According to the JCAHO, a physician's office history can be
copied and placed on an inpatient record if it dated within
_____ of admission.
General (includes vital signs)
HEENT, Chest, etc., Lab Data,
Plan for Admission,
Impression, etc.
8.
List three contents of a physical exam report.
24
9.
According to the JCAHO, the physical exam is to be completed
within the first _____hours of admission to the hospital
Interval
10.
When a patient is readmitted within 30 days for the same or a
related problem, which type of physical examination can be
written?
Comorbidity
11.
A coexisting condition is a(n):
Complication
12.
A condition which occurs during the hospitalization is the:
Physician’s Orders & Progress Notes
To direct the patient's care
during the hospitalization
13.
What is the function of physician's orders?
Standing Orders
14.
Name the type of orders physicians utilize for routine patient
care.
Discharge Order
15.
Which order is written to release the patient from the facility?
Against Medical Advice
(AMA)
16.
The patient who leaves the facility against express physician
orders leaves:
Telephone (Phone)
17.
Physicians are required to sign verbal orders within 24 hours
after they have been recorded in the patient's record. What
other types of orders must be signed within 24 hours of being
recorded?
Communication
18.
What do progress notes serve as among members of the
health care team?
Integrated
19.
When ancillary professionals document on the same progress
notes as physicians, what are these type of progress notes
called?
Discharge Note
20.
Physician progress notes should include an admission note,
follow-up progress notes and:
Admission
21.
The admission note summarizes the general condition of the
patient at the time of:
Condition
22.
Follow-up progress notes are to be written as frequently as
required by the patient's:
TRUE
23.
If the patient dies while in the hospital, the physician must still
document a final progress note. TRUE or FALSE.
Opinion
24.
The consultation report documents services rendered by a
physician whose ____ is requested.
Attending Physician
25.
Who is responsible for ordering a consultation?
(1) Patient whose diagnosis
is unclear. (2) Patient who
needs medical clearance for
surgery, etc.
26.
Provide two examples of a patient who would need to have a
consultation ordered.
Documentation that record
was reviewed, physical
examination of patient,
opinion, and
recommendations
27.
Name four of the content items that the consultation report
should contain.
Consultation Reports
Laboratory and Radiology Reports, and Nursing Documentation
Laboratory Report
28.
Which report involves the examination of materials, fluid and
tissues obtained from patients to aid in diagnosis and
treatment?
Nuclear Medicine Imaging
Report
29.
Which report describes diagnostic studies and therapeutic
procedures performed using radiopharmaceutical agents?
Radiographic (X-ray) Report
30.
Which report documents the interpretation of fluoroscopic
diagnostic services.
Attending Physician or
Consulting Physician
31.
Who orders diagnostic studies?
FALSE
32.
If a laboratory report is performed by an outside laboratory
(i.e., MDS of Olean), the original report is housed at the
outside laboratory and a copy of the report is placed on the
patient's record. TRUE or FALSE
Radiologist
24 Hours
33.
Radiologic reports are signed by the
patient's record within:
5 years
34.
The AOA/Conditions of Participation require Nuclear Medicine
Reports be retained for how many years?
Dosage
35.
When radiopharmaceutical agents are utilized to perform a
test, the agent, date and _____ of the radiopharmaceutical are
to be documented in the report.
Technologist
36.
The professionals responsible for signing the laboratory report
include the bacteriologist or _____ who performed the test.
Nurses Notes
37.
Which report "describes nursing observations of the patient,
care and treatment given, and the patient's response to
treatment"?
Assessment/evaluation,
nursing diagnosis, nursing
care provided, discharge
preparations, nursing
interventions
38.
State three of the six elements required in the nursing process
of documenting patient care.
Graphic Sheet
39.
Which provides for the nursing documentation of vital signs?
TPR
40.
What is the abbreviation for "temperature, pulse and
respiration"?
MAR (medication
administration record)
41.
Medications administered orally, topically, by injection,
inhalation or infusion are documented on the:
and filed in the
Nutrition Notes & Consent Forms
Dietary Technician
42.
The qualified dietitian or authorized designee is responsible for
documenting observations in the health record. Give an
example of the "authorized designee."
Progress Notes
43.
In which report would the dietitian document information
pertaining to a patient's dietary needs?
TRUE
44.
The JCAHO requires diet orders to be recorded in the patient's
record prior to serving the diet to the patient. TRUE or FALSE.
Battery
45.
If a patient undergoes treatment without having signed a
consent form, this is considered "unlawful touching" and is
called _____.
Liability
46.
If the patient is not required to sign a consent form prior to
treatment, this may result in _____ on the part of the facility.
Informed Consent
47.
The patient or representative should indicate in writing that
(s)he has been informed of the nature of the treatment, risks,
complications, alternate treatments and consequences of
treatment. This is called:
Operative Report, Anesthesia Record, Recovery Room Record and
Pathology Report
Operative Report
48.
The "operating room report" is also known as the:
Timely
49.
Documentation of surgical procedures must be complete and:
TRUE
50.
An operative record must be created for each procedure or
operation performed in the surgical suite. TRUE or FALSE.
Progress Note
51.
When there is a transcription delay, the Joint Commission
requires the surgeon to document an operative:
Condition of patient, unusual
events, operative findings,
specimens removed,
procedure performed,
preop/postop dx
52.
List 3 surgical items documented on the operating room report.
Preoperative Medications
53.
The anesthesia record documents anesthetic agents
administered during the operation and:
Evaluation of patient's
physical status, diagnostic
study results, choice of
anesthesia, procedure to be
performed, potential
anesthesia problems
54.
State 3 items documented on the preanesthetic evaluation.
Anesthesia Record (as well
as the MAR)
55.
Prior to induction of anesthesia, the patient's record indicates
time and dosage of administration of preanesthesia
medication. This is documented in doctor's orders and on the:
Progress Notes
56.
In addition, the appraisal of any changes in the patient's
condition would be documented in:
Unusual events, anesthesia
techniques used, anesthetic
agents administration, other
drugs administered, IV fluids,
blood/blood components
administered
57.
List 3 items documented on the anesthesia record.
Surgeon
58.
Which physician documents the order releasing a patient from
the recovery room?
Complications (if any),
abnormalities (if any), date,
time, swallowing reflex,
cyanosis (if any), patient's
condition
59.
List 3 items documented in the postanesthesia note.
Transfusion Record, Rehabilitation Reports, and Respiratory Therapy
Notes
TRUE
60.
The JCAHO requires that records be maintained that detail the
receipt and disposition of all blood products. TRUE or FALSE
Administration
61.
The transfusion record contains patient ID, blood group/Rh of
patient/donor, crossmatching, donor's ID #, and the record of
of the transfusion.
Physical therapy,
occupational therapy,
vocational/rehabilitative
services, psychiatric
services, prosthetic/orthotic
services, audiology, speech
pathology, etc.
62.
List three examples of rehabilitation services.
TRUE
63.
Special rehabilitation services are provided only upon
physician order. TRUE or FALSE
Monthly (timely)
64.
The "assessment of physical rehabilitation achievements and
estimates of further rehabilitation potential" is to be
documented at least ____.
Inhalation Therapy
65.
Respiratory therapy is also known as _____.
IPPB, etc.
66.
List one example of a respiratory therapy that would be
administered to the patient.
TRUE
67.
The JCAHO requires a "written prescription" for respiratory
therapy. This means that the therapy is administered only
upon physician's order. TRUE or FALSE
Discharge Summary, Autopsy Report, Emergency Department Record
Clinical Resume
68.
The discharge summary is known as the discharge abstract or:
Requests for information
(e.g., from other hospitals or
an insurance company
69.
The discharge summary contains information for continuity of
care, to facilitate medical staff committee review, and to
respond to:
48
70.
The JCAHO requires documentation of a discharge summary
on all cases except problems of a minor nature and those that
require less than
hours of hospitalization.
Reason for hospitalization
71.
The discharge summary includes a brief clinical statement of
the chief complaint and history of present illness. This is called
the:
Instructions
72.
The physician documents the medications that the patient is to
take after discharge in the
section of the discharge
summary.
Attending physician
73.
Who signs the discharge summary?
Events
74.
If the patient dies, a summation statement is added that
indicates reason for admission, findings during hospitalization,
hospital course, and ____ leading to death.
Necropsy
75.
The autopsy report is a.k.a. postmortem examination or:
3
76.
The JCAHO states that the autopsy provisional anatomic
diagnoses are to be recorded in the medical record within how
many days, and the complete protocol is to be made part of
the record within how many days?
Urgent
77.
The ED record describes the evaluation and management of
patients who come to the hospital emergency department for
immediate attention of medical conditions/traumatic injuries.
TRUE
78.
If a patient is admitted through the ED, the original ED record
is placed on the inpatient record. TRUE/FALSE
ER Physician
79.
Who is responsible for authenticating the emergency record?
COBRA of 1986
80.
Which law prevents hospitals from "dumping their indigent
patients on other institutions"?
Risk/benefits of transfer,
phone conversations re:
patient's condition, patient
request for transfer, patient's
condition upon transfer,
81.
State one criterion that the physician documents in the
emergency record about the transfer or the screening exam.
60
physician recommendation
for transfer
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