Chapter 6 Quiz Flashcards
. A pathology report is required
a. at the discretion of the pathologist.
b. at the discretion of the surgeon.
c. only in predefined cases where tissue is removed
d. whenever tissue (or other material)is removed
D
A provisional diagnosis is also known as a
a. co morbidity
b. final diagnosis
c. principal diagnosis
d. tentative diagnosis
D
The tissue report is the written report of findings on surgical specimens and is documented by the
a. attending physician
b. pathologist
c. radiologist
d. surgeon
B
Major sections of the history include
a. family and past history, mental and neuron-psychiatric exams, personal exams, and physical exams.
b. past history, family history, social history, review of systems, impression, and lab data.
c. past history, social history, chief complaint, present illness, and review of systems.
d. social and family history, past history, present illness, physical exam, and system review.
C
. A graphic record documents
a. the amount of medicine given per dose
b. the number of times a patient is visited by his doctor
c. the total number of times a patient has been in the hospital
d. vital signs throughout the patient’s stay.
D
Who provides the patient’s admitting diagnosis for an inpatient stay?
a. admitting office
b. attending physician
B
An operative record should contain a
a. description of the procedure
b. history of the anesthesia reactions
c. post-anesthesia status
d. vital signs
A
The history of present illness
a. describes the patients’ current illness
b. is a review of symptoms by body systems
c. is a statement about the patients’ life
d. summarizes the patient’s past illnesses
A
Where is the fact that a patient smokes cigarettes documented?
a. family history
b. physical examination
c. review of systems
d. social history
D
Laboratory tests are ordered by the
a. laboratory technician
b. medical technologist
c. pathologist
d. responsible physician
D
An “Impression” is most likely to be found on the
a. advances directive
b. discharge summary
c. face sheet
d. physical exam
D
The review of systems is found on the
a. history
b. physical examination
A
A patient is admitted on May 1 and discharged on May 2. The diagnosis is tonsillectomy, and the patient underwent routine tonsillectomy. Which applies?
a. A discharge note must be documented in the progress note.
b. A discharge summary must be dictated.
c. A short stay record may be documented.
d. An internal history and physical can be documented.
C
If the physician wants to determine how her patient reacted to a new medication administered during the night, she would review the
a. ancillary data
b. medication administration record
c. nurses notes
d. physician orders
C
Inpatient progress notes are documented
a. according to federal government mandates
b. as the patient’s conditions warrants
c. at least on a daily basis
d. more than one a day, as a minimum
B
The face sheet is also known as admission/discharge
a. record
b. register
A
The condition established after the study to be chiefly responsible for occasioning the admission of the patient to the hospital for care is the diagnosis
a. principal
b. principle
A
Which type of inpatient procedure is usually sequenced first?
a. diagnostic procedure to treat a complication .
b. diagnostic procedure to treat the reason for admission after study.
c. therapeutic procedure to treat a complication.
d. therapeutic procedure to treat the reason for admission after study.
D
. A coexisting condition is a
a. co-morbidity
b. complication
A
The best method of communication for members of the health care team caring for a hospital inpatient is the
a. consultation report
b. discharge summary
c. physicians report
d. progress report
D
. The description of surgical tissue analysis is found on the
a. autopsy report
b. laboratory report
c. operative report
d. pathology report
D
The choice of anesthesia to be administered during surgery is documented by the anesthesiologist on the
a. operative record
b. pre-anesthesia evaluation note
c. preoperative note
d. recovery room record
B
Progress Notes are a chronological report of the patient’s hospital course and reflect changes of the patient’s
a. data entries that direct patient treatment during an inpatient stay .
b. documentation of patient examination and review of the patient’s record.
c. evidence that sufficient treatment was rendered to justify the stay.
d. the only basis upon which the patient or payer is billed for the hospital stay.
C
Which is an ancillary service form?
a. flow sheet
b. laboratory report
c. medical administration record
d nursing discharge summary
B
Which statement would be documented in a physical examination?
a. admitted because of sharp epigastric pain
b. had cholecystectomy three years ago
c. HEAD: occasional headache
d. negative bowel sounds
D
