How can we help?

You can also find more resources in our Help Center.

27 terms

Chapter 3

STUDY
PLAY
discharge summary
The attending physician is responsible for which of the following types of acute care documentation.
problem list
which of the following is not usually a component of acute care patient records.
operative report
the number of ligatrues, sutures, packs, drains, and sponges used specimens removed would be found in
admitting diagnosis
which of the following is an example of clinical data.
emergency care record
which type of specialized record includes care provided prior to arrival at healthcare setting and times and means of arrival.
medical history
which of the following represents documentation of the patients current and past health status.
physical exam
which of the following contains the physicians findings based on an examination of the patient.
consultation report
documents opionions about the patients condition from the perspective of a physician not previously involved in the patients care.
present illness
in a medical history, which of the following is a detailed chronological description of the development of the patients illness.
physicians orders
to document the physicians instructions to other parties involved in providing care to a patient.
living will
which of the following is an example of a advance directive.
ambulatroy care
patient history questionnaires are most often used in:
operative report
which report in medical record includes name of doctors.
immuneizations
which of the following is not included in a an accute care record.
insurance company
which of the following is not considered clinical data.
clinical data
care driven directly related to patient
patients complete history
which of the following is not document in ER report
progress note
acute care record with chronilogical report to the persons stay in the hospital
cheif complaint
which part of the medical history documents the patients description in their own words
physical exam
contains physician findings based on an examination of the patient.
community mental healthcare
not long term care setting
correctional facility
in which setting may treatment chart travel with patient between treatment facilities.
hospice
family brevement
medication report
nurse responsible for which of the following type of acute care.
vital signs
which of the following would not be found in a medical history.
consultation
an attending physician requests the advice of a second physicaian who then reviews the health record and examines the patient. the second physician records impressions in what type of report.
care plan
which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps.