Chapter 5 – Answer Key – Worksheets
Face Sheet, Patient Assessment & Reassessment, History, Physical Examination, Admission/Discharge Record

Admission/Discharge Record

/ 1. / “Face Sheet” is also known as:
Clinical, Demographic, and Financial / 2. / The face sheet contains three types of information. Name them.
Patient Name, Address, Phone Number, etc. Insurance Company Name, Policy Number, etc. / 3. / Identify 4 common data elements collected on the face sheet.
History / 4. / The chief complaint is documented on the:
Provisional Diagnosis / 5. / The physician uses the above to establish the _____ diagnosis.
Review of Systems / 6. / The physician's assessment of all body systems is called the:
30 days / 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.
General (includes vital signs) HEENT, Chest, etc., Lab Data, Plan for Admission, Impression, etc. / 8. / List three contents of a physical exam report.
24 / 9. / According to the JCAHO, the physical exam is to be completed within the first _____hours of admission to the hospital
Interval / 10. / When a patient is readmitted within 30 days for the same or a related problem, which type of physical examination can be written?
Comorbidity / 11. / A coexisting condition is a(n):
Complication / 12. / A condition which occurs during the hospitalization is the:

Physician’s Orders & Progress Notes

To direct the patient's care during the hospitalization / 13. / What is the function of physician's orders?
Standing Orders / 14. / Name the type of orders physicians utilize for routine patient care.
Discharge Order / 15. / Which order is written to release the patient from the facility?
Against Medical Advice (AMA) / 16. / The patient who leaves the facility against express physician orders leaves:
Telephone (Phone) / 17. / Physicians are required to sign verbal orders within 24 hours after they have been recorded in the patient's record. What other types of orders must be signed within 24 hours of being recorded?
Communication / 18. / What do progress notes serve as among members of the health care team?
Integrated / 19. / When ancillary professionals document on the same progress notes as physicians, what are these type of progress notes called?
Discharge Note / 20. / Physician progress notes should include an admission note, follow-up progress notes and:
Admission / 21. / The admission note summarizes the general condition of the patient at the time of:

Condition

/ 22. / Follow-up progress notes are to be written as frequently as required by the patient's:
TRUE / 23. / If the patient dies while in the hospital, the physician must still document a final progress note. TRUE or FALSE.

Consultation Reports

Opinion

/ 24. / The consultation report documents services rendered by a physician whose ____ is requested.
Attending Physician / 25. / Who is responsible for ordering a consultation?
(1) Patient whose diagnosis is unclear. (2) Patient who needs medical clearance for surgery, etc. / 26. / Provide two examples of a patient who would need to have a consultation ordered.
Documentation that record was reviewed, physical examination of patient, opinion, and recommendations / 27. / Name four of the content items that the consultation report should contain.

Laboratory and Radiology Reports, and Nursing Documentation

Laboratory Report

/ 28. / Which report involves the examination of materials, fluid and tissues obtained from patients to aid in diagnosis and treatment?
Nuclear Medicine Imaging Report / 29. / Which report describes diagnostic studies and therapeutic procedures performed using radiopharmaceutical agents?
Radiographic (X-ray) Report / 30. / Which report documents the interpretation of fluoroscopic diagnostic services.
Attending Physician or Consulting Physician / 31. / Who orders diagnostic studies?
FALSE / 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
Radiologist 24 Hours / 33. / Radiologic reports are signed by the and filed in the patient's record within:
5 years / 34. / The AOA/Conditions of Participation require Nuclear Medicine Reports be retained for how many years?
Dosage / 35. / When radiopharmaceutical agents are utilized to perform a test, the agent, date and _____ of the radiopharmaceutical are to be documented in the report.
Technologist / 36. / The professionals responsible for signing the laboratory report include the bacteriologist or _____ who performed the test.
Nurses Notes / 37. / Which report "describes nursing observations of the patient, care and treatment given, and the patient's response to treatment"?
Assessment/evaluation, nursing diagnosis, nursing care provided, discharge preparations, nursing interventions / 38. / State three of the six elements required in the nursing process of documenting patient care.
Graphic Sheet / 39. / Which provides for the nursing documentation of vital signs?
TPR / 40. / What is the abbreviation for "temperature, pulse and respiration"?
MAR (medication administration record) / 41. / Medications administered orally, topically, by injection, inhalation or infusion are documented on the:

Nutrition Notes & Consent Forms

Dietary Technician

/ 42. / The qualified dietitian or authorized designee is responsible for documenting observations in the health record. Give an example of the "authorized designee."
Progress Notes / 43. / In which report would the dietitian document information pertaining to a patient's dietary needs?
TRUE / 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.
Battery / 45. / If a patient undergoes treatment without having signed a consent form, this is considered "unlawful touching" and is called _____.
Liability / 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.
Informed Consent / 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

Operative Report

/ 48. / The "operating room report" is also known as the:
Timely / 49. / Documentation of surgical procedures must be complete and:
TRUE / 50. / An operative record must be created for each procedure or operation performed in the surgical suite. TRUE or FALSE.
Progress Note / 51. / When there is a transcription delay, the Joint Commission requires the surgeon to document an operative:
Condition of patient, unusual events, operative findings, specimens removed, procedure performed, preop/postop dx / 52. / List 3 surgical items documented on the operating room report.
Preoperative Medications / 53. / The anesthesia record documents anesthetic agents administered during the operation and:
Evaluation of patient's physical status, diagnostic study results, choice of anesthesia, procedure to be performed, potential anesthesia problems / 54. / State 3 items documented on the preanesthetic evaluation.
Anesthesia Record (as well as the MAR) / 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:

Progress Notes

/ 56. / In addition, the appraisal of any changes in the patient's condition would be documented in:
Unusual events, anesthesia techniques used, anesthetic agents administration, other drugs administered, IV fluids, blood/blood components administered / 57. / List 3 items documented on the anesthesia record.
Surgeon / 58. / Which physician documents the order releasing a patient from the recovery room?
Complications (if any), abnormalities (if any), date, time, swallowing reflex, cyanosis (if any), patient's condition / 59. / List 3 items documented in the postanesthesia note.
Transfusion Record, Rehabilitation Reports, and Respiratory Therapy Notes

TRUE

/ 60. / The JCAHO requires that records be maintained that detail the receipt and disposition of all blood products. TRUE or FALSE
Administration / 61. / The transfusion record contains patient ID, blood group/Rh of patient/donor, crossmatching, donor's ID #, and the record of of the transfusion.
Physical therapy, occupational therapy, vocational/rehabilitative services, psychiatric services, prosthetic/orthotic services, audiology, speech pathology, etc. / 62. / List three examples of rehabilitation services.
TRUE / 63. / Special rehabilitation services are provided only upon physician order. TRUE or FALSE
Monthly (timely) / 64. / The "assessment of physical rehabilitation achievements and estimates of further rehabilitation potential" is to be documented at least ____.
Inhalation Therapy / 65. / Respiratory therapy is also known as _____.
IPPB, etc. / 66. / List one example of a respiratory therapy that would be administered to the patient.
TRUE / 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

Clinical Resume

/ 68. / The discharge summary is known as the discharge abstract or:
Requests for information (e.g., from other hospitals or an insurance company / 69. / The discharge summary contains information for continuity of care, to facilitate medical staff committee review, and to respond to:
48 / 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.
Reason for hospitalization / 71. / The discharge summary includes a brief clinical statement of the chief complaint and history of present illness. This is called the:
Instructions / 72. / The physician documents the medications that the patient is to take after discharge in the section of the discharge summary.
Attending physician / 73. / Who signs the discharge summary?
Events / 74. / If the patient dies, a summation statement is added that indicates reason for admission, findings during hospitalization, hospital course, and ____ leading to death.
Necropsy / 75. / The autopsy report is a.k.a. postmortem examination or:
3
60 / 76. / The JCAHO states that the autopsy provisional anatomic diagnoses are to be recorded in the medical record within how many days, and the complete protocol is to be made part of the record within how many days?
Urgent / 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.
TRUE / 78. / If a patient is admitted through the ED, the original ED record is placed on the inpatient record. TRUE/FALSE
ER Physician / 79. / Who is responsible for authenticating the emergency record?
COBRA of 1986 / 80. / Which law prevents hospitals from "dumping their indigent patients on other institutions"?
Risk/benefits of transfer, phone conversations re: patient's condition, patient request for transfer, patient's condition upon transfer, physician recommendation for transfer / 81. / State one criterion that the physician documents in the emergency record about the transfer or the screening exam.

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