Documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record? Personal Health Record. Which type of patient care record includes documentation of a family bereavement period?
Rationale: The patient's account information includes information about the patient's insurance. 16. Which of the following is an example of a long-term care setting? a. Assisted living facility
Represents the attending physician's assessment of the patient's current health status? Physical Examination. Patient history questionnaires are most often used in: Ambulatory Care.
Provides a chronological summary of the patient's medical history and illness b. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's caret d. Documents the physician's instructions to other parties involved in providing care to a patient
Which of the following is usually a component of acute care patient records? Progress notes are typically found in an acute care patient record.
26 Cards in this SetChapter 3Content and Structure of the Health RecordWhich of the following materials is not documented in an emergency care record?patient's instructions at dischargeWhich of the following types of facility is not governed by Medicare long-term care documentation standards?assisted living facilities23 more rows
Which of the following clinical data elements is not usually documented in the acute care health record? Providing information about the patient's insurance coverage.
The conditions of admission, consents and authorizations, physician progress notes, physician orders, anesthesia and sedation reports, interoperative records, emergency and ambulatory surgery records, and patient discharge instructions and referrals are paper documents.
Which of the following activities is not a traditional medical records function? Data administration. The only requirements for professional certification through the AHIMA are graduating from an accredited two-year or four-year educational program.
The main components of electronic health record are registration, admissions, discharge, and transfer (RADT) data.
TITLE: EMERGENCY ROOM RECORD PURPOSE: To provide a legal written record of medical/nursing care rendered and the patient's response to that care during his/her emergency room visit.
Administrative data include enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facility services, professional services, prescription drug services, laboratory services, and so on.
Which of the following should be taken into consideration when designing a health record form? File the record alphabetically by the last name, followed by the first name, and then the middle initial.
Here are the ten components of a medical record, along with their descriptions:Identification Information. ... Medical History. ... Medication Information. ... Family History. ... Treatment History. ... Medical Directives. ... Lab results. ... Consent Forms.More items...•
12-Point Medical Record Checklist : What Is Included in a Medical...Patient Demographics: Face sheet, Registration form. ... Financial Information: ... Consent and Authorization Forms: ... Release of information: ... Treatment History: ... Progress Notes: ... Physician's Orders and Prescriptions: ... Radiology Reports:More items...•
Electronic Health Records: The Basics Administrative and billing data. Patient demographics. Progress notes. Vital signs.