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chief complaint, history of present illness, past medical history, social history, family history, review of current systems, medication list

Patient history should include what seven items:

physical exam

This is an assessment of patient body systems to determine diagnosis.

provisional, differential, preadmission testing

The physical exam should document a _______ diagnosis, which may include a ______ diagnosis. It should also summarize the results of ________.

anesthesia record

Type of record that documents patient monitoring during administration of anesthetic agents.

preoperative, anesthesia, preoperative, intraoperative, postoperative, recovery

The anesthesia record documents administration of _____ meds, ______ administration during the operation, ______, _______, and _____ evaluation of patient, and ______ of patient.

operative record

Type of record that documents findings, procedures, and techniques associated with surgery.

principal participants

Who are the individuals identified in an operative record?

preoperative, postoperative, procedures, techniques, anesthesia, condition, all, findings

The operative record must indicate the _____ and ____ diagnosis, surgical _____ and _______, type of _______, the _____ of patient at ____ stages, and operative ______.

pathology report

Type of record that assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that was expelled by the patient.

clinical, pathologic, tissue, macroscopic, microscopic

The pathology report should contain a ______ and ______ diagnosis, ______ examination, ______ and _____ examination.

subjective, objective, assessment, plan

What are each of the elements of SOAP?


This is utilized for progress notes in the problem oriented record.


In SOAP progress notes, this section contains the patient's statement about how they feel.


In SOAP progress notes, this section contains information about the observations and physical findings derived from labs, x-rays, etc.


In SOAP progress notes, this section contains the judgment, opinion, or evaluation of the provider.


In SOAP progress notes, this section contains the diagnostic, therapeutic, and educational plans to resolve the problems.


Type of report that contains information documented by the lab, radiology, and nuclear medicine.

nursing notes

Daily patient observations are documented by nurses in these.

working, tentative, admitting, preliminary

Provisional diagnosis is also know as (four terms):


This diagnosis is entered upon entry to the hospital.

principal diagnosis

The condition established after study to be chiefly responsible for admission.

statute of limitations

Legally, what determines the length of time that a hospital must retain medical records?

attending physician

Which clinician is responsible for giving or administering orders?

five years

CoP requires that records be retained for a period of at least _____.

document, refuse to pay

If a provide performs a service but doesn't ______ it, the patient or third-party payer can _______.


A third party payer can refuse to pay for services if an _____ is used instead of real name.


Additional diagnoses that describe conditions arising after the beginning of hospital observation/treatment and that modify the course of illness or treatment.


The presence of one or more disorders in addition to the primary disease/disorder; because of presence with principal diagnosis, it will increase the length of stay.

24 hours

The Joint Commission and CoP require that the history and physical be performed and documented in patient record within ______ after admission.

completion of operation, transferred to next level of care

The JC requires that operative reports be written or dictated upon _______ and before patient is _________.

30 days

CoP requires that the history and physical be performed no more than ______ prior to admission.

30 days

Discharge summaries must be completed within ______ post discharge.

advance directive

Legal document in which the patient provides instructions as to how they want to be treated in the event they become very ill and there is no reasonable hope for recovery.

do not resuscitate

Legal document that tells medical professionals not to perform cardiopulmonary resuscitation in the event the patient's breathing or heartbeat stops.

living will

Legal document in which patients state the kind of health care they do or do not want under certain circumstances.

durable power of attorney

Legal document in which patients name someone close to them to make decisions about health care in the event they become incapacitated.

quantitative analysis

Review of patient record for completeness and chart deficiencies

qualitative analysis

Review of patient record for inconsistencies that may identify incomplete or inaccurate documentation

clinical data

Includes all health care information obtained about a patient's care and treatment.

administrative data

Includes demographic, socioeconomic, and financial information gathered upon admission to facility.

demographic data

Patient identification information collected according to facility policy and includes patient's name and other identifying information.

financial data

Includes information about insurance and third party payer.

legal health record

This serves as the legal business record of an organization and serves as evidence in lawsuits or other legal actions.


What constitutes an organization's legal health record varies depending on how the _______ defines it.

designated record set

Health records and records involved in billing, insurance enrollment and coverage, and other documents used in whole or in part to make decisions about individuals.


The designated record set encompasses ______ information than what is considered part of a legal health record.

organization, facility

The _______ or _______ has to determine which elements of the designated record set will be part of the legal health record.

any aspect

The legal health record is documentation of healthcare services provided to an individual during ________ of healthcare delivery.

upon request

The legal health record will be disclosed _______.

duplicate meanings, misunderstood

Abbreviations compromise patient safety because they can have _________ and be _____.

medical staff, one clear meaning

Concurrent and retrospective analysis of records should ensure that symbols and abbreviations have been approved by _____ and only have ________.

convert, complete words

Using abbreviations in EHRs can be dangerous because EHR systems can _______ abbreviations into _______.

organization specific

Organizations should adopt an approved ___________ abbreviation list.

HIPAA legislation

The designated record set is defined by _______.

may not

The legal health record _______ include all of the information in the designated record set.

federal regulation, state laws, accreditation body standards

The legal health record must meet requirements as defined by _______, _______, and _________.

use of abbreviations

The integrity of EHR documentation is more susceptible than paper records to ________.


Birth and death certificates are maintained _______ by the department of health.

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