Final  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"? "100 mg of penicillin per mouth administered at 8 a

1. 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

2. "100 mg of penicillin per mouth administered at 8 a.m." is an example of what kind of documentation?

Medication record

3. 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

4. Which of the following anesthesia reports would be used to document an unusual event or complication that occurred during surgery?

Postoperative

5. ___ 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

6. 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

7. 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

8. What term is used in reference to the patient care instructions that physicians give to other healthcare providers?

Physician's orders

9. 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

10. 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