ch. 11 study guide Flashcards
The assessment portion of the medical records helps to document the evaluation of the patient to ___________.
Form a diagnosis/treatment plan
The primary purpose of medical documentation is to help health professionals _______________________.
Communicate with one another
Physician’s _____________ consist of directives for tests, treatments, medications, and follow-up care.
orders
T/F: A patient’s medical record is considered a legal record of their medical history and health care.
True
A flow sheet contains a graphic record of a patient’s _____________.
Vital signs
Progress notes that record information in a paragraph style use a ________________ format.
Narrative
An ______________ sheet includes demographic data and insurance information provided by the patient prior to receiving care.
Admission
Military time is based on a ________ hour cycle.
24
Most health care facilities have converted from paper records to which format?
Electronic medical records
What are the benefits of using electronic physician’s orders?
Fewer errors due to lost paperwork/misread orders
What is the purpose of progress notes?
To record every contact a provider makes with a patient
Why is a family history included in the patient’s history?
Certain disorders and diseases are inherited
T/F: Health care facility quality assurance efforts include the review of patient medical records.
True
What is a problem-oriented medical record?
Organizes information according to the patient’s symptoms and complaints
What is objective data in a medical record as opposed to subjective data?
- Objective data: includes information from the health care professional’s observations from the patient
- Subjective data: includes any statements from the patient describing his or her condition.
