Answer Key - Worksheets - Content of the Patient Records ...

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Chapter 5 – Answer Key – Worksheets | |

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|Face Sheet, Patient Assessment & Reassessment, History, Physical Examination, Admission/Discharge Record |

|Admission/Discharge Record |1. |“Face Sheet” is also known as: |

|Clinical, Demographic, and Financial |2. |The face sheet contains three types of information. Name them. |

|Patient Name, Address, Phone Number, etc. |3. |Identify 4 common data elements collected on the face sheet. |

|Insurance Company Name, Policy Number, etc. | | |

|History |4. |The chief complaint is documented on the: |

|Provisional Diagnosis |5. |The physician uses the above to establish the _____ diagnosis. |

|Review of Systems |6. |The physician's assessment of all body systems is called the: |

|30 days |7. |According to the JCAHO, a physician's office history can be copied and placed on an |

| | |inpatient record if it dated within _____ of admission. |

|General (includes vital signs) HEENT, Chest, |8. |List three contents of a physical exam report. |

|etc., Lab Data, Plan for Admission, Impression,| | |

|etc. | | |

|24 |9. |According to the JCAHO, the physical exam is to be completed within the first _____hours|

| | |of admission to the hospital |

|Interval |10. |When a patient is readmitted within 30 days for the same or a related problem, which |

| | |type of physical examination can be written? |

|Comorbidity |11. |A coexisting condition is a(n): |

|Complication |12. |A condition which occurs during the hospitalization is the: |

|Physician’s Orders & Progress Notes |

|To direct the patient's care during the |13. |What is the function of physician's orders? |

|hospitalization | | |

|Standing Orders |14. |Name the type of orders physicians utilize for routine patient care. |

|Discharge Order |15. |Which order is written to release the patient from the facility? |

|Against Medical Advice (AMA) |16. |The patient who leaves the facility against express physician orders leaves: |

|Telephone (Phone) |17. |Physicians are required to sign verbal orders within 24 hours after they have been |

| | |recorded in the patient's record. What other types of orders must be signed within 24 |

| | |hours of being recorded? |

|Communication |18. |What do progress notes serve as among members of the health care team? |

|Integrated |19. |When ancillary professionals document on the same progress notes as physicians, what are|

| | |these type of progress notes called? |

|Discharge Note |20. |Physician progress notes should include an admission note, follow-up progress notes and:|

|Admission |21. |The admission note summarizes the general condition of the patient at the time of: |

|Condition |22. |Follow-up progress notes are to be written as frequently as required by the patient's: |

|TRUE |23. |If the patient dies while in the hospital, the physician must still document a final |

| | |progress note. TRUE or FALSE. |

|Consultation Reports |

|Opinion |24. |The consultation report documents services rendered by a physician whose ____ is |

| | |requested. |

|Attending Physician |25. |Who is responsible for ordering a consultation? |

|(1) Patient whose diagnosis is unclear. (2) |26. |Provide two examples of a patient who would need to have a consultation ordered. |

|Patient who needs medical clearance for | | |

|surgery, etc. | | |

|Documentation that record was reviewed, |27. |Name four of the content items that the consultation report should contain. |

|physical examination of patient, opinion, and | | |

|recommendations | | |

|Laboratory and Radiology Reports, and Nursing Documentation |

|Laboratory Report |28. |Which report involves the examination of materials, fluid and tissues obtained from |

| | |patients to aid in diagnosis and treatment? |

|Nuclear Medicine Imaging Report |29. |Which report describes diagnostic studies and therapeutic procedures performed using |

| | |radiopharmaceutical agents? |

|Radiographic (X-ray) Report |30. |Which report documents the interpretation of fluoroscopic diagnostic services. |

|Attending Physician or Consulting Physician |31. |Who orders diagnostic studies? |

|FALSE |32. |If a laboratory report is performed by an outside laboratory (i.e., MDS of Olean), the |

| | |original report is housed at the outside laboratory and a copy of the report is placed |

| | |on the patient's record. TRUE or FALSE |

|Radiologist 24 |33. |Radiologic reports are signed by the and filed in the patient's record within: |

|Hours | | |

|5 years |34. |The AOA/Conditions of Participation require Nuclear Medicine Reports be retained for how|

| | |many years? |

|Dosage |35. |When radiopharmaceutical agents are utilized to perform a test, the agent, date and |

| | |_____ of the radiopharmaceutical are to be documented in the report. |

|Technologist |36. |The professionals responsible for signing the laboratory report include the |

| | |bacteriologist or _____ who performed the test. |

|Nurses Notes |37. |Which report "describes nursing observations of the patient, care and treatment given, |

| | |and the patient's response to treatment"? |

|Assessment/evaluation, nursing diagnosis, |38. |State three of the six elements required in the nursing process of documenting patient |

|nursing care provided, discharge preparations, | |care. |

|nursing interventions | | |

|Graphic Sheet |39. |Which provides for the nursing documentation of vital signs? |

|TPR |40. |What is the abbreviation for "temperature, pulse and respiration"? |

|MAR (medication administration record) |41. |Medications administered orally, topically, by injection, inhalation or infusion are |

| | |documented on the: |

|Nutrition Notes & Consent Forms |

|Dietary Technician |42. |The qualified dietitian or authorized designee is responsible for documenting |

| | |observations in the health record. Give an example of the "authorized designee." |

|Progress Notes |43. |In which report would the dietitian document information pertaining to a patient's |

| | |dietary needs? |

|TRUE |44. |The JCAHO requires diet orders to be recorded in the patient's record prior to serving |

| | |the diet to the patient. TRUE or FALSE. |

|Battery |45. |If a patient undergoes treatment without having signed a consent form, this is |

| | |considered "unlawful touching" and is called _____. |

|Liability |46. |If the patient is not required to sign a consent form prior to treatment, this may |

| | |result in _____ on the part of the facility. |

|Informed Consent |47. |The patient or representative should indicate in writing that (s)he has been informed of|

| | |the nature of the treatment, risks, complications, alternate treatments and consequences|

| | |of treatment. This is called: |

|Operative Report, Anesthesia Record, Recovery Room Record and Pathology Report |

|Operative Report |48. |The "operating room report" is also known as the: |

|Timely |49. |Documentation of surgical procedures must be complete and: |

|TRUE |50. |An operative record must be created for each procedure or operation performed in the |

| | |surgical suite. TRUE or FALSE. |

|Progress Note |51. |When there is a transcription delay, the Joint Commission requires the surgeon to |

| | |document an operative: |

|Condition of patient, unusual events, operative|52. |List 3 surgical items documented on the operating room report. |

|findings, specimens removed, procedure | | |

|performed, preop/postop dx | | |

|Preoperative Medications |53. |The anesthesia record documents anesthetic agents administered during the operation and:|

|Evaluation of patient's physical status, |54. |State 3 items documented on the preanesthetic evaluation. |

|diagnostic study results, choice of anesthesia,| | |

|procedure to be performed, potential anesthesia| | |

|problems | | |

|Anesthesia Record (as well as the MAR) |55. |Prior to induction of anesthesia, the patient's record indicates time and dosage of |

| | |administration of preanesthesia medication. This is documented in doctor's orders and on|

| | |the: |

|Progress Notes |56. |In addition, the appraisal of any changes in the patient's condition would be documented|

| | |in: |

|Unusual events, anesthesia techniques used, |57. |List 3 items documented on the anesthesia record. |

|anesthetic agents administration, other drugs | | |

|administered, IV fluids, blood/blood components| | |

|administered | | |

|Surgeon |58. |Which physician documents the order releasing a patient from the recovery room? |

|Complications (if any), abnormalities (if any),|59. |List 3 items documented in the postanesthesia note. |

|date, time, swallowing reflex, cyanosis (if | | |

|any), patient's condition | | |

|Transfusion Record, Rehabilitation Reports, and Respiratory Therapy Notes |

|TRUE |60. |The JCAHO requires that records be maintained that detail the receipt and disposition of|

| | |all blood products. TRUE or FALSE |

|Administration |61. |The transfusion record contains patient ID, blood group/Rh of patient/donor, |

| | |crossmatching, donor's ID #, and the record of of the transfusion. |

|Physical therapy, occupational therapy, |62. |List three examples of rehabilitation services. |

|vocational/rehabilitative services, psychiatric| | |

|services, prosthetic/orthotic services, | | |

|audiology, speech pathology, etc. | | |

|TRUE |63. |Special rehabilitation services are provided only upon physician order. TRUE or FALSE |

|Monthly (timely) |64. |The "assessment of physical rehabilitation achievements and estimates of further |

| | |rehabilitation potential" is to be documented at least ____. |

|Inhalation Therapy |65. |Respiratory therapy is also known as _____. |

|IPPB, etc. |66. |List one example of a respiratory therapy that would be administered to the patient. |

|TRUE |67. |The JCAHO requires a "written prescription" for respiratory therapy. This means that |

| | |the therapy is administered only upon physician's order. TRUE or FALSE |

|Discharge Summary, Autopsy Report, Emergency Department Record |

|Clinical Resume |68. |The discharge summary is known as the discharge abstract or: |

|Requests for information (e.g., from other |69. |The discharge summary contains information for continuity of care, to facilitate medical|

|hospitals or an insurance company | |staff committee review, and to respond to: |

|48 |70. |The JCAHO requires documentation of a discharge summary on all cases except problems of |

| | |a minor nature and those that require less than hours of hospitalization. |

|Reason for hospitalization |71. |The discharge summary includes a brief clinical statement of the chief complaint and |

| | |history of present illness. This is called the: |

|Instructions |72. |The physician documents the medications that the patient is to take after discharge in |

| | |the section of the discharge summary. |

|Attending physician |73. |Who signs the discharge summary? |

|Events |74. |If the patient dies, a summation statement is added that indicates reason for admission,|

| | |findings during hospitalization, hospital course, and ____ leading to death. |

|Necropsy |75. |The autopsy report is a.k.a. postmortem examination or: |

|3 |76. |The JCAHO states that the autopsy provisional anatomic diagnoses are to be recorded in |

|60 | |the medical record within how many days, and the complete protocol is to be made part of|

| | |the record within how many days? |

|Urgent |77. |The ED record describes the evaluation and management of patients who come to the |

| | |hospital emergency department for immediate attention of medical |

| | |conditions/traumatic injuries. |

|TRUE |78. |If a patient is admitted through the ED, the original ED record is placed on the |

| | |inpatient record. TRUE/FALSE |

|ER Physician |79. |Who is responsible for authenticating the emergency record? |

|COBRA of 1986 |80. |Which law prevents hospitals from "dumping their indigent patients on other |

| | |institutions"? |

|Risk/benefits of transfer, phone conversations |81. |State one criterion that the physician documents in the emergency record about the |

|re: patient's condition, patient request for | |transfer or the screening exam. |

|transfer, patient's condition upon transfer, | | |

|physician recommendation for transfer | | |

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