Stack 3873854 Medical Terminology and Health Records

Stack #3873854 Question The Blank______ section of a health record tells the patient's story of their health issues. When describing the directions on the human body, you must use the _______ position Which of the following is a specially trained in treating patients respiratory issues under the guidance of a health care provider. What is the abbreviation for "Electronic Health Record"? Forming a logical analysis is in the _________ part of the SOAP method. The main reason for the patient's visit is the Afebrile Progressive Symptom Lethargic Noncontributory Hereditary Farther away from the center is Consultation notes are written by the consulting physician and sent to the Blank______. Writes reports for patient care under the supervision of a nurse Writes reports for radiologic procedures Writes reports for pathology ad laboratory A health care professional who is specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan is called a Correct documentation in a patent's chart can prevent which of the following? A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health is the Which of the following is the documentation method used for charting in the medical record? What type of documentation format is used for consultation notes? Pediatrician Anesthesiologist EMT Surgeon What type of information is recorded on the emergency department note? After the medical history is obtained and the physical exam is completed, the attending medical professional writes a detailed Which of the following are acceptable methods of documentation in the patient's chart? What factor in the discharge summary is different from the general SOAP documentation method? Which of the following physicians document the operative report on the patient? Answer subjective anatomic Respiratory Therapist EHR assessment chief complaint To not have a fever More and more each day Something a patient feels A decrease in level of consciousness Not related to this specific problem Runs in the family distal PCP Primary Care Physician MA Medical Assistant Radiologist Pathologist Dietician Adverse outcomes Potentially fatal outcomes social history SOAP Subjective blue, Objective red, Assessment yellow, Plan green SOAP A physician who treats children A physician who specializes in pain control and sedation. Trained in emergency care and transport of the patient. A physician who treats patient surgically. Patient assessment Diagnostic tests Plan of care Admission summary Dictated Handwritten Electronic The note will lead with the diagnosis. Surgeon Which of the following are the elements documented in the operative report prepared by the surgeon? A discharge summary note details Blank______ and Blank______ a patient was admitted. Which of the following physicians document the operative report on the patient? What is the name of the report documented by the health care provider who assesses the patient's care each day? Most patients seen by the medical staff in an emergency department are what type of patients? Events that transpired Procedure performed Patient surgical outcome Which of the following is mentioned in a pathology report? What was seen in detail Reason for the study Pathologist's assessment differential diagnosis. How patient felt when admitted What types of follow-up are required What happened during patient's stay at the hospital The assessment is also known as a(n) Which of the following are documented in the discharge summary of a patient? Which of the following abbreviations means "intensive care unit"? Which of the following report explains the reason for ordering a radiologic image. How often are progress notes documented in the patient's chart? How often are progress notes documented in the patient's chart? (R) VS L The pathology report is very similar to which type of report? The second line of the prescription, which provides the patient's instructions, is the Which of the following abbreviations means "after surgery"? Which of the following are documented on the radiology report? Which of the following is mentioned in a pathology report? The third line of the prescription, which tells the pharmacist how much medication to give the patient, is called The prescription form is documented in the ____________ part of the SOAP method. BID TID QHS QD QID Which abbreviation means "after meals"? when; why surgeon Daily Report Progress Note new ICU radiology daily (B) Right Vital Signs left Radiology report sig. post-op Reason image was ordered How image was performed Radiologist assessment What was seen in detail Reason for the study Pathologist's assessment dispense plan Twice daily Three time a day At night Daily four times daily PC