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Stack #145338

What consists of a patient's name, medical number, date of birth, and social security number? Patient identification
The face sheet contains what information? Patient identification, demographic, financial data, and clinical information.
Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care? Principal diagnosis
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
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
What is the generalized consent that documents a patient's consent to receive medical treatment at the facility? Consent to admission
What provides information for continuity of care and facilitates medical staff committee review? Discharge summary
Where is the patient's chief complaint recorded? History
What is an assessment of the patients body systems? Physical examination
What indicates that several diagnoses are being considered as possible? Differential diagnosis
The provision of health care services by a consulting physician whose opinion or advice is requested by another physician? Consultation
What directs the diagnostic and therapeutic patient care activities? Physician orders
Orders that are hand written in a paper based record or entered into an electronic record are? Written orders
Physician orders preapproved by the medical staff, which are pre-printed and placed on a patients record are? Routine orders
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
What contains statements related to the course of the patient's illness, response to treatment, and status at discharge? Progress notes
A majority of care is delivered to inpatients by? Nursing staff
What documents patient's vital signs using a graph for easy interpretation of data? Graphic sheet
Contents of neonatal records include: Birth history, newborn identification, newborn physical exam, newborn progress notes.
An autopsy is also called? Necropsy
Created by: angieb1



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