Instructions: Respond to each using Chapter 5 of your textbook.
Obtain the worksheet answer key from your instructor.
Face Sheet, Patient Assessment & Reassessment, History, Physical Examination
1. / "Face Sheet" is also known as:
2. / The face sheet contains two types of information. Name them.
3. / Identify 4 common data elements collected on the face sheet.
4. / The chief complaint is document on the:
5. / The physician uses the above to establish the diagnosis.
6. / The physician's assessment of all body systems is called the:
7. / According to the JCAHO, a physician’s office history can be copied and placed on an inpatient record if it dated within of admission.
8. / List three contents of a physical exam report.
9. / According to the JCAHO, the physical exam is to be completed within the first hours of admission to the hospital.
10. / When a patient is readmitted within 30 days for the same or a related problem, a(n) physical examination can be written.
11. / A coexisting condition is a(n) .
12. / A condition which occurs during the hospitalization is the:
Physician’s Orders, Progress Notes, Pathology Reports
13. / What is the function of physician’s orders?14. / Name the type of orders physicians utilize for routine patient care.
15. / Which order is written to release the patient from the facility.
16. / The patient who leaves the facility against express physician orders leaves .
17. / Physicians are required to sign verbal or orders within 24 hours after they have been recorded in the patient's record.
18. / Progress notes serve as a means of among members of the health care team.
19. / When ancillary professionals document on the same progress notes as physicians, these are called progress notes.
20. / Physician progress notes should include an admission note, follow-up progress notes and .
21. / The admission note summarizes the general condition of the patient at the time of .
22. / Follow-up progress notes are to be written as frequently as required by the patient's .
23. / If the patient dies while in the hospital, the physician must still document a final progress note. TRUE or FALSE.
Consultation Reports
24. / The consultation report documents services rendered by a physician whose ____ is requested.25. / Who is responsible for ordering a consultation?
26. / Provide two examples of a patient who would need to have a consultation ordered.
27. / Name four of the content items that the consultation report should contain.
Laboratory and Radiology Reports, and Nursing Documentation
28. / Which report involves the examination of materials, fluid and tissues obtained from patients to aid in diagnosis and treatment?29. / Which report describes diagnostic studies and therapeutic procedures performed using radiopharmaceutical agents?
30. / Which report documents the interpretation of fluoroscopic diagnostic services.
31. / Who orders diagnostic studies?
32. / If a laboratory report is performed by an outside laboratory (i.e., MDS of Olean), the original report is housed at the outside laboratory and a copy of the report is placed on the patient's record. TRUE or FALSE
33. / Radiologic reports are signed by the and filed in the patient's record within .
34. / The AOA/Conditions of Participation require Nuclear Medicine Reports be retained for .
35. / When radiopharmaceutical agents are utilized to perform a test, the agent, date and of the radiopharmaceutical are to be documented in the report.
36. / The professionals responsible for signing the laboratory report include the bacteriologist or who performed the test.
37. / Which report "describes nursing observations of the patient, care and treatment given, and the patient's response to treatment"?
38. / State three of the six elements required in the nursing process of documenting patient care.
39. / Which provides for the nursing documentation of vital signs?
40. / What is the abbreviation for "temperature, pulse and respiration"?
41. / Medications administered orally, topically, by injection, inhalation or infusion are documented on the .
Nutrition Notes, Consent Forms
42. / The qualified dietitian or authorized designee is responsible for documenting observations in the health record. Give an example of the "authorized designee."43. / In which report would the dietitian document information pertaining to a patient's dietary needs?
44. / The JCAHO requires diet orders to be recorded in the patient's record prior to serving the diet to the patient. TRUE or FALSE.
45. / If a patient undergoes treatment without having signed a consent form, this is considered "unlawful touching" and is called _____.
46. / If the patient is not required to sign a consent form prior to treatment, this may result in _____ on the part of the facility.
47. / The patient or representative should indicate in writing that (s)he has been informed of the nature of the treatment, risks, complications, alternate treatments and consequences of treatment. This is called ______.
Operative Report, Anesthesia Record, Recovery Room Record and Pathology Report
48. / The "operating room report" is also known as the:
49. / Documentation of surgical procedures must be complete and:
50. / An operative record must be created for each procedure or operation performed in the surgical suite. TRUE or FALSE.
51. / When there is a transcription delay, the Joint Commission requires the surgeon to document an operative:
52. / List 3 surgical items documented on the operating room report.
53. / The anesthesia record documents anesthetic agents administered during the operation and:
54. / State 3 items documented on the preanesthetic evaluation.
55. / Prior to induction of anesthesia, the patient's record indicates time and dosage of administration of preanesthesia medication. This is documented in doctor's orders and on the ____.
56. / In addition, the appraisal of any changes in the patient's condition would be documented in:
57. / List 3 items documented on the anesthesia record.
58. / Which physician documents the order releasing a patient from the recovery room?
59. / List 3 items documented in the postanesthesia note.
Transfusion Record, Rehabilitation Reports, and Respiratory Therapy Notes
60. / The JCAHO requires that records be maintained that detail the receipt and disposition of all blood products. TRUE or FALSE61. / The transfusion record contains patient ID, blood group/Rh of patient/donor, crossmatching, donor's ID #, and the record of of the transfusion.
62. / List three examples of rehabilitation services.
63. / Special rehabilitation services are provided only upon physician order. TRUE or FALSE
64. / The "assessment of physical rehabilitation achievements and estimates of further rehabilitation potential" is to be documented at least ____.
65. / Respiratory therapy is also known as _____.
66. / List one example of a respiratory therapy that would be administered to the patient.
67. / The JCAHO requires a "written prescription" for respiratory therapy. This means that the therapy is administered only upon physician's order. TRUE or FALSE
Discharge Summary, Autopsy Report, Emergency Department Record
68. / The discharge summary is known as the discharge abstract or:69. / The discharge summary has information for continuity of care, to facilitate medical staff committee review, and to respond to:
70. / The JCAHO requires documentation of a discharge summary on all cases except problems of a minor nature and those that require less than hours of hospitalization.
71. / The discharge summary includes a brief clinical statement of the chief complaint and history of present illness. This is called the:
72. / The physician documents the medications that the patient is to take after discharge in the section of the discharge summary.
73. / Who signs the discharge summary?
74. / If the patient dies, a summation statement is added that indicates reason for admission, findings during hospitalization, hospital course, and ____ leading to death.
75. / The autopsy report is a.k.a. postmortem examination or:
76. / The JCAHO states that the autopsy provisional anatomic diagnoses are to be recorded in the medical record within days, and the complete protocol is to be made part of the record within days.
77. / The ED record describes the evaluation and management of patients who come to the hospital emergency department for immediate attention of medical conditions/traumatic injuries.
78. / If a patient is admitted through the ED, the original ED record is placed on the inpatient record. TRUE/FALSE
79. / Who is responsible for authenticating the emergency record?
80. / Which law prevents hospitals from "dumping their indigent patients on other institutions"?
81. / State one criterion that the physician documents in the emergency record about the transfer or the screening exam.
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