233-237 Flashcards
Define disposition or discharge.
The removal of a patient from inpatient treatment
According to the text, what are some examples of patient dispositions?
Return to duty; discharge from treatment; evacuate to US; separate or retire due to physical disability; transfer out
When completing an AF Form 560, in which item would you document all diagnoses and procedures of a patient’s case?
Item 38, Diagnosis–Procedures
How are surgical procedures entered on AF Form560?
Numbered with the principal procedure listed first, and then those that are associated procedures.
In which item of AF Form 560 is the nature of a patient’s disposition recorded?
Item 41, Disposition.
What source documents do you use to input information about a patient’s discharge into the CHCS?
AF Form 560 and the inpatient record.
A patient with an illness that is severe, but there is no imminent danger to the patient’s life.
Seriously ill.
A patient’s injuries resulted in seriousdisfigurement
Incapacitating illness or injury.
A condition so severe that there is imminent danger to thepatient’s life.
Very seriously ill.
On what form does the health care provider annotate the decision to report a patient in SI, VSI, or III status?
AF Form 3066, Doctor’s Orders.
On what form, does the casualty affairs liason (CAL) annotate individuals who are notified of a patient’s casualty status?
AF Form 570.
For what purpose is the AF Form 1403, used?
To list patients on casualty status.
Who approves an attending physician’s recommendation for the presence of the NOK when it would be beneficial to the patient’s recovery?
MTF commander.
Under what circumstances is each military branch allowed to pay for the travel of a patient’s NOK?
For military VSI and SI active duty militarypatients.
Who is responsible for verifying deaths that occur in an MTF and on Air Force installations?
Physician
Within how many hours after death are remains released to mortuary personnel?
24
To whom is the personal property of an active duty deceased forwarded?
Appointed summary court officer.
To whom are the personal effects of civilians forwarded?
Executor or administration, or, if none is appointed, to the nearest NOK
Who is responsible for all health record entries regarding diagnoses and procedures?
Health care providers
Where is a copy of the death certificate filed?
Inpatient record
What minimum information is required on each form in the inpatient record?
Patient’s name, register number, name of MTF providing treatment, name of MTF maintaining records if different than admitting MTF, family member prefix and SSN.
Who is the approval authority for a postmortem examination?
Installation commander.
Who is responsible for the completion of the death certificate?
Physician.
What type of duties can you expect to perform while assigned to an inpatient unit?
Health services management duties.
How are corrections to inpatient records made?
Line through incorrect data, do not erase or scratch out. If space permits enter correct data next to erroneous data, if not draw a line through erroneous data, initial and place the correct date next to the entry. Make a note that refers the reader to the correct entry. Go to the location on the inpatient form where the next entry can be made and enter the information using the current date.
How are medical records-progress notes used?
Used by the physician, dentist, and/or certified nurse midwife to chronologically document the patient’s progress while admitted to the hospital
What form is used by a physician to transmit written orders for patient care to the nursing staff?
Used by the physician, dentist, and/or certified nurse midwife to chronologically document the patient’s progress while admitted to the hospital
Who authorizes patient absences from the hospital?
Health care provider.
What happens when an active duty member leaves the hospital without proper authorization?
They are considered AWOL.
What patient absence is granted to active duty members and is considered part of the patient’s treatment?
Convalescent leave.
What form is used to authorize a patient pass?
AF Form 569.
What is the difference between directed and recommended convalescent leave?
Directed refers to active duty patient’s still admitted to the MTF. The chief of service approves these cases. Recommended refers to active duty patients being discharged. The patient’s unit commander approves these cases.
