- What type of report would be issued after a urinalysis was performed?
Laboratory
- A _______________ is defined as a condition that began after the patient was admitted for inpatient care.
complication
- Generally, which of the following people does have authority to disclose protected health information?
-A parent or legal guardian on behalf of a minor child or legally incompetent adult
-The executor or administrator of an estate if the patient is deceased
-The patient, if the patient is a competent adult or emancipated minor
- Accreditation standards and the Medicare Conditions of Participation require that the patient's ________________ be documented by the attending physician in the patient's health record no more than thirty days after discharge.
principal diagnosis
- Specific instructions for patient care after discharge are called ___________________.
discharge instructions
- The discharge summary must be completed within ___________ after discharge for most patients but within _______________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than ________________ hours.
30 days/24 hours/48 hours
- The _________________ is the condition established, after study, to have been the main reason for the patient's admission for inpatient treatment.
principal diagnosis
- Health problems or conditions, present in the patient before admission, that affected the patient's care are called_________________.
comorbidities
- A concise account of the patient's illness, course of treatment, response to treatment, and condition at discharge is called a:
Discharge summary
- Who is responsible for writing and signing discharge summaries and discharge instructions?
The attending physician
