Stack #145338
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| What consists of a patient's name, medical number, date of birth, and social security number? | Patient identification
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| The face sheet contains what information? | Patient identification, demographic, financial data, and clinical information.
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| Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care? | Principal diagnosis
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| A legal document in which patients provide instructions as to how they want to be treated in the event they become very ill and there is no responsible hope for recovery? | Advance directive
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| Pre-existing condition that will, because of its presence with a specific principal diagnosis, cause an increase in the patient's length of stay by at least one day in 75% of the cases? | Comorbidities
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| What is the generalized consent that documents a patient's consent to receive medical treatment at the facility? | Consent to admission
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| What provides information for continuity of care and facilitates medical staff committee review? | Discharge summary
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| Where is the patient's chief complaint recorded? | History
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| What is an assessment of the patients body systems? | Physical examination
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| What indicates that several diagnoses are being considered as possible? | Differential diagnosis
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| The provision of health care services by a consulting physician whose opinion or advice is requested by another physician? | Consultation
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| What directs the diagnostic and therapeutic patient care activities? | Physician orders
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| Orders that are hand written in a paper based record or entered into an electronic record are? | Written orders
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| Physician orders preapproved by the medical staff, which are pre-printed and placed on a patients record are? | Routine orders
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| Physicians orders preapproved by the medical staff that direct the continual administration of specific acivities for a specific period of time as a part of diagnostic or therapeutic care? | Standing order
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| What contains statements related to the course of the patient's illness, response to treatment, and status at discharge? | Progress notes
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| A majority of care is delivered to inpatients by? | Nursing staff
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| What documents patient's vital signs using a graph for easy interpretation of data? | Graphic sheet
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| Contents of neonatal records include: | Birth history, newborn identification, newborn physical exam, newborn progress notes.
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| An autopsy is also called? | Necropsy
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