Shared Flashcard Set

Details

Chapter 3 Review
Review of Chapter 3 HIT workbook
36
Health Care
09/18/2012

Additional Health Care Flashcards

 


 

Cards

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
pathology report
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
admission order
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
laboratory report
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
nursing progress note
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
operative consent
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
newborn record
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
nursing flow record
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
discharge summary
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
ECG report
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
radiology report
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
consultation report
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
social work note
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
home health care
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
emergency care
Term
Identify the specialty facility record where the documentation noted would most frequently be found:

care plan, physical and psychosocial assessments, bereavement documentation
Definition
hospice care
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
behavioral health care
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
long term care
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
rehabilitative care
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
end stage renal disease
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
ambulatory care
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
ambulatory surgery
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