Term
Identify the acute care record report where the following information would be found:
HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma.
CHEST: Good bilateral chest sounds. |
|
Definition
| physical examination report |
|
|
Term
Identify the acute care record report where the following information would be found:
Microscopic: Sections are of squamous mucosa with no atypia. |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
Admit to 3C. Diet: NPO
Meds: Compazine 10mg IV Q 6 PRN |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
MD in AM. Discharge instructions given to patient and he verbalized understanding. Discharged to home with family. Gait steady. |
|
Definition
nursing discharge note
(vs just a discharge summary) |
|
|
Term
Identify the acute care record report where the following information would be found:
CBC: WBC 12.0H, RBC 4.65,
HGB 14.8, HCT 43.3, MCV 93 |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
c/o slight tingling in fingers, better when arm out of sling, fingers warm, color pink, wiggles fingers, will monitor |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
authorize and direct William Smith, MD, my surgeon, and/or associates of his choice to perform the following operation upon me. |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry, to room with mom |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
Vital signs:
Time: 0120 T 36, P 144, R 46
0430 T 37, P 132, R 36
0800 T 37, P 112, R 50 |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
Diagnoses: chronic atrial fibrillation, congestive heart failure, old myocardial infarction. She will be followed by me in the office. |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
PA and Lateral Chest: the lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine. |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
I was asked to evaluate this Level I trauma patient with a open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture. |
|
Definition
|
|
Term
Identify the acute care record report where the following information would be found:
Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family. |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
aide recording of bathing, cooking, and cleaning; nursing and therapy assessments |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
emergency care given to a patient prior to arrival and pertinent history and physical findings and vital signs upon arrival |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
care plan, physical and psychosocial assessments, bereavement documentation |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
patient’s legal status, individualized treatment plan, documentation of seclusion or restraints, psychologist notes |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
RAI and care plan, nutritional services and activities documentation |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
functional and disability diagnoses, evidence of patient/family participation in decisions, staff conference reports |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
documentation of the patient’s nutritional, anemia, vascular access, and transplant status; dialysis doses |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
documentation of all medications including over the counter drugs provided, dental examination, medical and psychological evaluations |
|
Definition
| correctional facility care |
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
patient problem list, patient history questionnaire, progress notes |
|
Definition
|
|
Term
Identify the specialty facility record where the documentation noted would most frequently be found:
preoperative studies, operative report, anesthesia report, documentation of follow-up phone calls |
|
Definition
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Acute care hospitals |
|
Definition
| AOA, Joint Commission, Medicare |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Ambulatory care/physician office settings |
|
Definition
| AAAHC, AOA, Joint Commission, NCQA (managed care), Medicare (rural clinics) |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Ambulatory surgery facilities |
|
Definition
| American Association for Ambulatory Surgery Facilities, AOA, Joint Commission, Medicare |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Long-term care facilities |
|
Definition
| CARF (assisted living), Joint Commission, Medicare (skilled nursing) |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Behavioral healthcare facilities |
|
Definition
| AOA, CARF, Council on Quality and Leadership in support for People with Disabilties, Joint Comission, Medicare (some providers) |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Health care in correctional facilities |
|
Definition
| American Correctional Association, National Commission on Correctional Health Care, Joint Commission |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
End stage renal disease care settings |
|
Definition
| Medicare, see also specific setting where dialysis care is provided |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Home health organizations |
|
Definition
| Joint Commission, National League for Nursing, Medicare |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Hospice organizations |
|
Definition
| Joint Commission, Medicare |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Obstetric/gynecologic care settings |
|
Definition
| American College of Obstetricians and Gynecologists, see also ambulatory care: AAAHC, AOA, Joint Commission, NCQA (managed care), Medicare (rural clinics) |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Pediatric care settings |
|
Definition
| see ambulatory care: AAAHC, AOA, Joint Commission, NCQA (managed care), Medicare (rural clinics) |
|
|
Term
Identify the organizations that accredit or certify each of the following types of facilities following the example provided:
Rehabilitation services organizations |
|
Definition
| AOA, CARF, Joint Commissions , Medicare |
|
|
