25 terms

HIM Final Exam part two

advanced directive
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