Exam 4: The Patient Record: Hospital, Physician Office, and Alternate Care Settings

At times it is necessary for a provider to amend an entry in a patient record by adding a(n) _________ to the record to clarify, add additional information about previous documentation or enter a late entry.

Tom Black falls while transferring from his bed to a wheelchair. This would be documented on a(n)

The medical record is the property of the provider.

Nurse Jones takes a telephone order from Dr. Blake. Determine which of the following should occur.

Operative reports, laboratory reports, and nursing intake/output records are types of ____________________.

Records maintained by alternate care settings vary because of the types of services delivered, _________________________, and state and federal regulations.

The abbreviation NPO means

A signature legend identifies the author of a record entry by full signature when initials are used in the patient record.

Ms. Smith analyzes patient records for deficiencies and determines that there are entries that have been authenticated using initials. She needs to identify the author of these entries to clarify information. She should reference the ____ to determine the full name of the author of the entries.

An admissions clerk enters "right lower abdominal pain" as the admission diagnosis on the face sheet. This information is known as

Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie's attending physician. Who must sign the history and physical?

Medicare Conditions of Participation require hospitals to retain medical records for a period of no less than five years.

An inpatient record is typically between ____ in length.

At times, corrections need to be made in paper-based record systems. Explain the procedure for correcting an entry.

To calculate the delinquent record rate, divide the total number of delinquent records by the

Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient's record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the ____ data recorded in the record.

Explain how Joint Commission standards address verbal orders.

A patient's name, Social Security number, and date of birth are types of ____________________ data.

When signing a patient record entry, the author should minimally sign with the first initial, last name, and ____________________ or discipline.

The ____________________ is responsible for performing an admission history and physical examination on the patient.