Deck 4: Acute Care Records

Question 1

Obstetrical records differ from other types of acute care records because:

A) Prenatal care data is collected earlier and transferred to the hospital
B) Obstetricians are not required by the TJC to collect a patient history and physical
C) The newborn is not considered an admission
D) The mother is not considered an admission

Answer 1

Prenatal care data is collected earlier and transferred to the hospital

Question 2

Which of the following is not a necessary part of a medication record?

A) The physician's signature
B) The dosage of the medication
C) The name of the nurse who administered the medication
D) The date and time of administration

Answer 2

The physician's signature

Question 3

In acute care, physician's progress notes are:

A) Written at least daily to validate the need for care
B) Sometimes collected by physician residents, provided they are countersigned by the attending physician
C) Only collected by the attending physician
D) Both A and B

Answer 3

Both A and B

Question 4

Which of the following is an element of an acute care admission record?

A) Patient's previous operations
B) Type of dwelling in which the patient lives
C) Name of patient's employer
D) Patient's height and weight

Question 5

All of the following are elements of the UHDDS EXCEPT:

A) Principal diagnosis
B) Race
C) Marital status
D) Disposition

Question 6

CMS allows some patients to stay in the hospital up to 48 hours for monitoring without being admitted. This is called _____________ status.

A) elective
B) observation
C) emergency
D) urgent

Question 7

All of the following are elements of the UHDDS EXCEPT:

A) Date of birth
B) Gender
C) Religion
D) Discharge date

Question 8

If there is one physical location within the hospital for all patient registration activities, the registration function is said to be:

A) Centralized
B) Decentralized
C) Admissions
D) Departmental

Question 9

All of the following are always elements of a physician's order EXCEPT:

A) Date
B) Physician's signature
C) Initials/signature of the individual executing the order
D) Reason/rationale for the order

Question 10

All of the following are typical elements of an inpatient admission record EXCEPT:

A) Home telephone number
B) Religion
C) Insurance carrier, if any
D) Vital signs

Question 11

If a hospital wanted to correspond with a patient after discharge, the appropriate source of the patient's current address would be the:

A) Discharge summary
B) Attending physician's office records
C) History and physical
D) Latest admission record

Question 12

What is one distinguishing factor between emergent and urgent care?

A) Patient presents with life-threatening condition
B) Social status
C) Health insurance coverage
D) Patient has appointment

Question 13

The extent and complexity of a history and physical are dictated by:

A) TJC guidelines
B) DHHS guidelines
C) Data needed to evaluate the patient's problem
D) All of the above

Question 14

The best place to look to determine what medications a patient has received is the:

A) Physician's orders
B) Physician's progress notes
C) Nursing medication administration record
D) Discharge summary

Question 15

Which of the following data elements is NOT likely to appear on an acute care admission record?

A) Patient's religion
B) Patient's date of birth
C) Name of the patient's spouse
D) Tobacco use by the patient

Question 16

A cardiology consultation is typically requested by:

A) Attending physician
B) Nursing
C) Patient
D) All of the above

Question 17

Which of the following would NOT be found on an admission record or face sheet?

A) admitting diagnosis
B) patient name
C) nursing progress notes
D) attending physician

Question 18

Records that typically incorporate physician office data into the inpatient record are _____ records.

A) Intensive care
B) Neonatal
C) Obstetrical
D) Operative

Question 19

In a paper record, the admission record is often synonymous with the:

A) History and physical
B) Nursing assessment
C) Face sheet
D) Demographic data

Question 20

A problem-focused physical examination focuses on which of the following body areas and organ systems?

A) All body areas and organ systems.
B) Only the head, neck, chest and abdomen
C) Only the patient's general appearance, and his or her vital signs
D) Only the body area(s) or organ system(s) affected

Question 21

There may be a(n) ______________ on the patient's wristband, readable by machine, which connects the patient to his or her medical record.

Question 22

Which of the following should be collected during the patient registration process?

A) A plan of care, the measures to treat the patient's condition or disease
B) An advance directive, to specify the patient's wishes for his/her care
C) A discharge summary, to recap the patient's stay
D) A history, to document the patient's previous treatments

Question 23

When a patient is first seen by a physician in any health care setting, the physician generally records the patient's chief complaint, pertinent family and social data, and a review of the patient's body systems. This record is called the ________.

Question 24

The attending physician provides a(n) _____________ to explain the reason for admission.

Question 25

A _________ is called when an attending physician would like a specialist to review a patient case.

Question 26

Routine documentation of the nurse's interaction with a patient is recorded in the __________.

Question 27

A predetermined set of instructions for a specific set of blood tests, x-rays, or other procedures is called:

A) Plan of care
B) Protocol
C) Utilization review
D) Verbal orders

Question 28

In a patient's history, the reason the patient presented for evaluation and treatment is called the_________________ complaint.

Question 29

During registration, the patient signs a(n) _____________ to grant the hospital permission to provide general diagnostic and therapeutic care, as well as to release information to a third party payer.

Question 30

In urgent situations, a physician's office may call a facility in advance to order an admission. This is called a ____________.

Question 31

The physician's operative report must be completed:

A) Prior to the procedure
B) During the procedure
C) Immediately after the procedure
D) Within 30 days of the patient's discharge from the hospital

Question 32

The first page, also known as the face sheet, in a paper record is usually the ___________.

Question 33

The best place to find the medications administered during an operation is:

A) Physician's orders
B) Operative report
C) Nursing medication administration record
D) Anesthesia record

Question 34

__________ is the care provided through the use of mobile technology that allows care providers to view and consult patients from satellite locations.

Question 35

Laboratory tests performed at the time of the patient's admission help identify preexisting infections conditions. An infection identified after 48 hours of hospitalization is called a ____________ infection, and is attributed to the facility.

Question 36

In order to ____________ a document or other data collection device, a physician may sign the document or enter a password.

Question 37

If a health care professional is working under the supervision of another, such as a resident being supervised by an attending physician, then the notes written by that professional must be _________________ by the supervisor.

Question 38

In caring for a patient, an attending physician may request a(n) ___________ from another physician or health care professional who specializes in the patient's problem.

Question 39

All of the following data are needed for a physician's verbal order EXCEPT:

A) the nurse's authentication
B) the name of the patient
C) the time of the physician's authentication
D) the name of the payer or guarantor

Question 40

The physician who is primarily responsible for coordinating the care of the patient in the hospital is the ___________.

Question 41

Name and describe the four scenarios that inpatient admissions correspond to.

Question 42

Match the following parts of the patient record with their source or recorder.

A) health care facility identification number
B) vital signs
C) patient identity
D) discharge summary
1. Patient registration
2. Attending physician (or his/her designee)
3. Nurse/nursing staff
4. Maintained in system files

Question 44

Match the UHDDS data element with the correct category.

A) Expected source of payment
B) Principal diagnosis
C) Race and ethnicity
D) Date of birth
5. Demographic data
6. Socioeconomic data
7. Financial data
8. Clinical data

Question 46

Match the following terms with their definitions.
a. Laboratory tests
b. Medication sheet
c. Nursing assessment
d. Operation
e. Operative report
f. Physical examination
g. Physician's orders
h. Plan of treatment
i. Progress notes
j. Radiology tests
k. Rule out
l. SOAP format
9. Acronym that describes the medical decision-making process. It also refers to the way physicians organize their progress notes
10. Analysis of body fluids
11. Examination of a patient using x-rays
12. One or more surgical procedures performed at the same time
13. Record of all drugs given to a patient during the hospitalization
14. The diagnostic, therapeutic, or palliative measures that will be taken to investigate or treat the patient's condition or disease
15. The nurse's evaluation of the patient
16. The physician's directions regarding the patient's care. Also refers to the data collection device on which these elements are captured
17. The physician's documentation of a surgical procedure, usually dictated and transcribed
18. The physician's documentation of the examination of the patient, particularly at the initial visit
19. The physician's record of each visit with the patient
20. The process of systematically eliminating potential diagnoses. Also refers to the list of potential diagnoses

Question 48

What is the documentation standard for History and Physicals (H&Ps) established by the Joint Commission?

Question 49

Describe the events that will occur when a patient is admitted to an acute care facility for a surgical procedure. What caregivers will be involved with the patient?

Question 50

Compare and contrast the physician's SOAP strategy of documentation with the nursing strategy of documentation. Why are they different?

Question 51

What is the purpose of the admission consent form? Why do patients have to sign this, and what permissions are given to the health care facility when a patient signs?

Question 52

List the UHDDS elements of a patient abstract. Explain how this information is captured.

Question 53

What are essential elements in the operative report? List at least five.