1.
1st outpatient visit is called the ______ visit, and the 2nd visit is called the _______ visit.: Initial, subsequent
2.
4 types of medical decision making, in order of complexity from most to least complex: High, moderate, low, straightforward
3.
4 types of patient status: New, Established, Outpatient and Inpatient
4.
5 types of presenting problems from the most risk and least recovery to least risk and most recovery: High severity, moderate severity, low severity, self-limited/minor, minimal severity
5.
Advice or opinion from one physician to another physician: Consultation
6.
An inventory of body systems obtained through questioning to identify signs and/or symptoms that the patient may be experiencing is a ____ of _____: Review of systems
7.
Attention to an acute illness or injury that results in hospitalization: Admission
8.
Complexity of medical decision making is based on 3 _____: Elements
9.
Counseling and coordination of care are what kind of factors in most cases?: Contributory
10.
Discussion with a patient and/or family concerning 1 or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies, prognosis, risks and benefits of treatment is ______: Counseling
11.
Evaluation and determination f care for a newborn infant: Newborn care
12.
Face to face encounter between the physician and patient: Office visit
13.
First 3 factors a coder must consider when coding are patient ______, ________, and _______: Patient status, type of service, place of service
14.
How many types of histories are there?: 4
15.
If the physician who is standing by does so for 25 minutes, can he or she round the time up to 30 minutes for reporting purposes?: No
16.
Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time?: Unit/floor
17.
Is examination of the back an organ system or body area examination?: BA
18.
One who has been formally admitted to an acute health care facility: Inpatient
19.
One who has not been formally admitted to a health care facility: outpatient
20.
One who has not received services from the physician or another physician in the same group (and specialty) within the last 3 years: New Patient
21.
One who has received services from the physician or another physician in the same group within the last 3 years.: Established patient
22.
Services rendered by a physician whose opinion or advice is request by another physician or agency in the evaluation and/or treatment of a patient is a _____, whereas the physician who has primary responsibility for the patient in the hospital is called ______: Consultation, attending
23.
Term used to describe a patient who has been formally admitted to a hospital: Inpatient
24.
The 4 types of examinations in order of difficulty (least to most difficult): Problem focused, expanded problem focused, detailed, and comprehensive
25.
The examination that is limited to the affected body area is the _____: Problem focused
26.
The history is the ______ information the patient tells the physician.: Subjective
27.
The patients ______ _______ will reflect the number of systems examined by a brief statement of the findings.: Medical record
28.
There is no distinction made between the new and established patients in this service department of a hospital: Emergency
29.
Time that is used as a guide for outpatient services is what kind of time?: Face to face or direct
30.
What does VLBW stand for?: Very low birth weight
31.
What is the name for the assumption of the total or specific care of a patient from one physician to another that does no constitute a consultation?: Transfer of care
32.
When care is provided for similar services to the same patient by more than one physician on the same day for different conditions, the care is ______: Concurrent
33.
When critically ill patients in medical emergencies require the constant attendance of the physician to stabilize them, what kind of care is needed?: Critical care
34.
Which history is more complex; the problem focused history or the expanded problem focused history?: Expanded problem focused
