Chapter 6 Quiz

Question 1

. 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

Answer 1

D

Question 2

A provisional diagnosis is also known as a

a. co morbidity
b. final diagnosis
c. principal diagnosis
d. tentative diagnosis

Answer 2

D

Question 3

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

Answer 3

B

Question 4

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.

Answer 4

C

Question 5

. 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.

Answer 5

D

Question 6

Who provides the patient’s admitting diagnosis for an inpatient stay?

a. admitting office
b. attending physician

Answer 6

B

Question 7

An operative record should contain a

a. description of the procedure
b. history of the anesthesia reactions
c. post-anesthesia status
d. vital signs

Answer 7

A

Question 8

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

Answer 8

A

Question 9

Where is the fact that a patient smokes cigarettes documented?

a. family history
b. physical examination
c. review of systems
d. social history

Answer 9

D

Question 10

Laboratory tests are ordered by the

a. laboratory technician
b. medical technologist
c. pathologist
d. responsible physician

Answer 10

D

Question 11

An “Impression” is most likely to be found on the

a. advances directive
b. discharge summary
c. face sheet
d. physical exam

Answer 11

D

Question 12

The review of systems is found on the

a. history
b. physical examination

Answer 12

A

Question 13

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.

Answer 13

C

Question 14

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

Answer 14

C

Question 15

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

Answer 15

B

Question 16

The face sheet is also known as admission/discharge

a. record
b. register

Answer 16

A

Question 17

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

Answer 17

A

Question 18

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.

Answer 18

D

Question 19

. A coexisting condition is a

a. co-morbidity
b. complication

Answer 19

A

Question 20

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

Answer 20

D

Question 21

. The description of surgical tissue analysis is found on the

a. autopsy report
b. laboratory report
c. operative report
d. pathology report

Answer 21

D

Question 22

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

Answer 22

B

Question 23

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.

Answer 23

C

Question 24

Which is an ancillary service form?

a. flow sheet
b. laboratory report
c. medical administration record
d nursing discharge summary

Answer 24

B

Question 25

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

Answer 25

D