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Stack #145338
| Question | Answer |
|---|---|
| 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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