Chapter 6

Question 1

patient rights acknowlegement

Answer 1

a listing of guarantees that a patient should expect, including the right to privacy, the right to make one’s own medical decisions, the right to refuse treatment, and the right t be treated fairly

Question 2

nursing assessment

Answer 2

the documentation of nursing interview and exam performed immediately or shortly after admission that details information such as means of admission (by wheelchair, ambulatory, etc.), reason for admission, events leading to admission, presence of chronic conditions, current medications, drug allergies, person to contact in case of emergency, and whether the patient can perform typical activities of daily living

Question 3

advance directive

Answer 3

a document listing a patient’s wishes, should he or she be unable to make decisions for him- or herself, or the naming of an individual who is authorized to do so.

Question 4

property and valuables inventory

Answer 4

a listing of all the personal property (Clothing, jewelry, prosthetic devices, wallet, money etc.) the patient had on his or her person when arriving in the hospital room

Question 5

charting by exception

Answer 5

documentation based on occurrences that are out of the norm or documentation of complaints voiced by the patient. Examples include:

• patient stating that his pain is worse than it had been
• the fact that a patient was combative
• the fact that a patient walked to the bathroom without calling for assistance, even thought he was to be non-ambulatory

Question 6

template

Answer 6

a preformatted document, found in software, that prompts structured responses in the EHR

Question 7

Medication Administration Record (AMR)

Answer 7

documentation of each medication administered, the dosage, the rout of administration, the time and date administered, and the name of the person administering the medication

Question 8

Attending Physician

Answer 8

the physician responsible for the care of a patient while hospitalized

Question 9

Hospitalist

Answer 9

a physician, employed by a hospital and is typically a board-certified internist or family practitioner, responsible for admitting patients, following and assessing patients as needed, and writing orders as necessary

Question 10

verbal order

Answer 10

an order given to a nurse either in person or over the phone, then later authenticated by the physician or the physician extender

Question 11

observation

Answer 11

a patient status used when the patient’s condition does not warrant an inpatient level of care but does require observation by medical personnel. Observation typically lasts from 24 hours to no more than 48 hours.

Question 12

History of present illness (HPI)

Answer 12

the symptoms or circumstances leading the patient to seek medical intervention

Question 13

Review of systems (ROS)

Answer 13

a system by system set of questions asked of a patient regarding symptoms he or she may be experiencing

Question 14

Pathologist

Answer 14

a physician whose specialty is dealing with the analysis of a tissue sample to establish a diagnosis

Question 15

autopsy

Answer 15

an examination performed after death to examine organs and tissue in order to determine cause of death

Question 16

post- anesthesia care unit (PACU)

Answer 16

the unit to which a patient is transferred following surgery for monitoring of vial signs and condition post-surgery

Question 17

durable medical equipment (DME)

Answer 17

medical equipment meant to be used for long periods, such as hospital beds, hearing aids, orthotics, and protheses

Question 18

apgar score

Answer 18

a newborn assessment done at one minute and five minutes after birth to assess the newborn’s respiratory function, heart rate, muscle tone, reflexes, and skin color

Question 19

computerized physician order entry (CPOE)

Answer 19

electronic means of ordering tests and medications that also provides clinical advice about the drug, the dosage, and any contraindications

Question 20

admission, discharge, and transfer (ADT) system

Answer 20

electronic tracking of the registrations, admissions, discharges, and transfers occurring in a hospital at nay given time. It is sometimes referred to as RADT (R for registration)

Question 21

patient census

Answer 21

the number of inpatients occupying beds at any given time

Question 22

bar code

Answer 22

a machine-readable code consisting of vertical parallel bars and white space. Every scanned document contains a bar code identifying the patient and the encounter to which the document belongs. the bar code then matches that document to the correct patient and encounter within the EHR

Question 23

point of care

Answer 23

the physical location where a health care professional delivers services to a patient

Question 24

interface

Answer 24

a program that allows two or more similar or different devices to communicate and be interoperable

Question 25

claims data

Answer 25

billing codes that physicians, pharmacies, hospitals, and other healthcare providers submit to payers. these data have the benefit of following a relatively consistent format and of using a standard set of ICD-9/10 codes.