Final   Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay? What type of health record documentation represents a chronological record of the patient's condition and response to treatment throughout his or her hospital stay? Which of the following is a written description of a healthcare facility's procedures on the use and disclosure of protected health information? What type of health record documentation would a physician use to give a nurse the following instructions: "Give 100 mg of penicillin, tid"? What type of health record documentation would a nurse use to document a patient's reaction to anesthesia and condition after surgery? "Mother died of breast cancer; father still living but has heart disease" is an example of what type of health record documentation? What type of health record documentation includes aftercare instructions for the patient and/or his or her caregiver? What type of report would be issued after a tilt-table test was performed? What type of report would be issued after an electroencephalogram was performed? What type of report would be issued after a CT scan was performed?

1. Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay?

Uniform Ambulatory Care Data Set

2. What type of health record documentation represents a chronological record of the patient's condition and response to treatment throughout his or her hospital stay?

Progress notes

3. Which of the following is a written description of a healthcare facility's procedures on the use and disclosure of protected health information?

Notice of privacy practices

4. What type of health record documentation would a physician use to give a nurse the following instructions: "Give 100 mg of penicillin, tid"?

Physician's order

5. What type of health record documentation would a nurse use to document a patient's reaction to anesthesia and condition after surgery?

Recovery room record

6. "Mother died of breast cancer; father still living but has heart disease" is an example of what type of health record documentation?

History report

7. What type of health record documentation includes aftercare instructions for the patient and/or his or her caregiver?

Discharge instructions

8. What type of report would be issued after a tilt-table test was performed?

Cardiology

9. What type of report would be issued after an electroencephalogram was performed?

Neurology

10. What type of report would be issued after a CT scan was performed?

Imaging