Exam 6: Content of the Patient Record: Inpatient, Outpatient, and Physician Office

Upcoding or maximizing codes is considered DRG creep.

The role of a forms committee is to review all proposed forms to be used in the patient record.

The history of the present illness is the patient's own description of his or her current medical condition.

An autopsy would be performed in all of the following cases except

A patient is admitted for congestive heart failure and hypertension. During the admission, the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a

The diagnosis that documents the condition or disease for which the patient is seeking treatment is the

Physician orders preapproved by the medical staff, which are preprinted and placed on a patient's record, are called ____________________.

An APGAR score is documented in the

Explain the role of the forms committee.

An inventory of body systems to reveal subjective symptoms stated by the patient is called the ____________________.

Which of the following would not be documented on a medication administration record?

A consent to admission documents a patient's consent for all medical treatment including procedures and surgeries to be completed during the current admission.

A licensed nurse is required to have a public license to deliver care to patients.

As Ms. RHIT assembles and analyzes a discharged obstetrical patient's record, she finds the forms listed below. Which should be pulled from the discharged patient's record? ​ Face sheet Admission history and physical exam Consents Patient's property record Insurance claim Laboratory reports Antepartum record (copy) Labor and delivery record Incident report Postpartum record ​

The death certificate is usually filed with a state department of health's office of vital statistics within five days.

Molly Mapes was admitted to Sunny Valley Hospital on January 22 (this year) for pneumonia. The history and physical examination (H&P) was placed on the record January 24 (this year). Which of the following statements is true, based on Joint Commission standards?

Sally Smith is admitted to Sunny Valley Hospital wearing a diamond ring. This should be documented on the

All orders must be authenticated by the responsible provider.

Patient identification information can be imprinted on forms by using a(n) ____________________.

Clinical data contains all health care information obtained about a patient's care and treatment.