Question | Answer |
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
a.surgery 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 |