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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.


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.


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.


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.

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