HIM Final Exam part two

25 terms by heather4476

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example of a living will

present illness

in a medical history, which of the following is a detailed chronological description of the development of the patients illness

ambulatory care

patient history questionnaires are most often common in

physical examination

represents the attending physicians assessment of the patients current health status

community mental health centers

which is not a an example of a long term care setting? assisted living facilities, intermediate care facilities, community mental health centers, subacute care organizations

Long term care

an RAI/MDS and are plan are found in records of patients in _____.

correctional facility care

in which setting may treatment records travel with the patient between centers? ambulatory care, behavioral healthcare, correctional facility care, long term care

personal health record

documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal family, occupational and environmental histories are maintained over a lifetime in what type of record? correctional facility health record, end stage renal disease record, long term care record, personal health record

hospice record

which type of patient care record includes documentation of a family bereavement period?

use black pen to obliterate the entry

when correcting erroneous information in a health record, which of the following is not appropriate?

joint commission

which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits

home health

documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record

commission on accreditation of rehabilitation services

which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities

standardized familiar format

an advantage of paper based records is :

electronic record

type of new technological savvy health record is designed to measure clinical outcomes, collect data a the point of care, and provide medical alerts

document imaging

an example of data capture technology

conditions of participation

general name for medicare standards impacting healthcare organizations

physical examination

HEENT reveals the tympanic membranes, nares and pharynx to be clear, no obvious head trauma, chest good bilateral chest sounds

pathology report

microscopic sections are squamous mucosa with no atypia

admission report

admit to 3C, diet: NPO Meds: compazine 10mg IV Q 6 PRN

Operation report

following induction of an adequate general anesthesia and with thpatient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion

nursing discharge report

MD in the Am discharge instructions given to patient and he verbalized understanding discharged to home with family gait steady

Laboratory report

CBC WBC 12.0 H , RBC 4.65 , HGB 14.8

nursing progress report

C/O slight tingling in fingers, better when arm out of sling, fingers warm, color pink

Operative consent

I authorize and direct William Smith , MD, my surgeon to perform surgery on me

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