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medical records

reviewing a pt's medical record, looking for new orders/changes in pt status are parts of the inital ___ ____ review. a.patient status b.PT intervention c.medical record d.dr order medical record
what form will include Patients name age, marital status, type of insurance admitting diagnosis date of admission and MD? a.medical b.identification c.history d.physician orders identification
what form will a pt sign for surgeries,procedures and may have advance living will or medical power of attorney report b.medical record c.progress d.consent consent
what would include the ROS, MD examination, proglem list primarary/secondary Dx, and POC? a.medical report b.progress notes c.physician orders d.Hx and Physical exam Hx and physical exam
H&P stands for? history and physical
how would a MD proceed with evaluating a pt for a Rehab center? a.consent and release form b.physician orders c.consultation d.specialized report consultation
where do healthcare providers and the MD write comments about the pt condition and to communicate to other healthcare providers? a.medical report b.physician's orders c.progress notes d.specialized reports progress notes
where would you find all orders for tests, medication, PT, nursing, diet and Rx? a.consultations b.consent and release forms c.medication record d.physician's orders physician's orders
where would you find the discription of anesthesia, and transcribed description of the Sx? surgery report
what holds every medication and nursing medication sheets? a.specialized reports b.medication record c.progress notes d.medical record medication record
x-ray reports, lab reports,imaging reports and EKG's would be included in what? a.consent reports b.consultations c.physician's orders d.specialized reports specialized reports
heart rate, tempature, blood pressure and respiratory rate would be included in the daily? a.progress reports b.nurses notes c.specialized reports d.vital signs vital signs
where would you find the intial PT eval, brief Hx, subjective comments, LTG, and may be in a SOAP format? a.physician report b.consultation report c.physical therapy section d.medical records physical therapy section
Created by: heatxfer



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