Chapter 1 Terms

Question 1

past and current medical conditions along with a head to toe assessment

Answer 1

history and physical

Question 2

care, medications, tests, and treatments

Answer 2

physicians orders

Question 3

record of all that is done for a patient

Answer 3

nurses notes

Question 4

physicians ongoing record

Answer 4

physicians progress notes

Question 5

a record by specialists who have seen the patient or reviewed the medical record

Answer 5

consultation reports

Question 6

reports of procedures or therapies by departments such as physical therapy or respiratory therapy

Answer 6

ancillary reports

Question 7

an important section which contains reports of tests ordered by the physician

Answer 7

diagnostic reports

Question 8

permission for treatment; may also include the purpose, risks, and benefits of a procedure

Answer 8

informed consent

Question 9

a record dictated by the physician containing all details of a specific surgical procedure

Answer 9

operative report

Question 10

a document of the drugs used for anesthesia and the patients response to them and the surgery

Answer 10

anesthesiologists report

Question 11

findings of an examination of tissues of organs removed during a surgical procedure

Answer 11

pathologists report

Question 12

a final record of all that occured during a patients hospitalization with follow up plans

Answer 12

discharge summary

Question 13

short term care for those needing diagnosis, treatment, surgery, emergency, or obstetrical care

Answer 13

acute care/general hospitals

Question 14

examples are burn or birthing centers and psychiatric hospitals

Answer 14

specialty care hospitals

Question 15

provide medical care or assistance for persons who cannot care for themselves

Answer 15

nursing homes or long term care facilities

Question 16

one day diagnostic tests, treatment, and procedures are provided.

Answer 16

ambulatory care centers, surgical centers, or outpatient clinincs

Question 17

diagnosis and treatment in a private setting

Answer 17

physicians offices

Question 18

known by a variety of names, primary and specialized care is provided in a prepaid system

Answer 18

health maintenance organization

Question 19

Nursing, therapy, personal care, and housekeeping services are provided in the patients home

Answer 19

home health care

Question 20

in patient and outpatient services provide physical and occupational therapies as well as speech therapy psychological services

Answer 20

rehabilitation centers

Question 21

inpatient care and home care are for terminally ill patients and their families

Answer 21

hospices