- In which of the following types of health record documentation would you find statements like this one: "Specimen consists of normal fallopian tubes and ovaries and uterus showing submucus leiomyomas"?
Pathology reports
- "100 mg of penicillin per mouth administered at 8 a.m." is an example of what kind of documentation?
Medication record
- Under which circumstances may an interval note be added to a patient's health record in place of a complete history and physical?
When the patient is readmitted within thirty days of the initial treatment for the same condition
- Which of the following anesthesia reports would be used to document an unusual event or complication that occurred during surgery?
Postoperative
- ___ Why was the International Implant Registry created in 1988?
To track patients who have had implants in order to notify them of potential safety concerns
- Which of the following terms is used in reference to a written document that describes the patient's healthcare preferences in the event he or she becomes unable to communicate directly in the future?
Advance directive
- Which of the following types of physician documentation is used to document the patient's own description of his or her present illness?
History report
- What term is used in reference to the patient care instructions that physicians give to other healthcare providers?
Physician's orders
- Which type of documentation summarizes the date, time, and method of admission as well as the patient's current condition, symptoms, and vital signs?
Initial assessment
- What type of documentation represents a concise description of the patient's illness, course of treatment, response to treatment, and condition at the time he or she left the hospital?
Discharge summary