Chapter 6 - The Active Health Record in Acute Care Settings

Question 1

Patient rights acknowledgement

P. 146

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 to be treated fairly.

Question 2

Nursing assessment

P. 147

Answer 2

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

Question 3

Advance directive

P. 147

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

p. 147

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

P. 148

Answer 5

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

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

Question 6

Template

P. 148

Answer 6

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

Question 7

Medication administration record (MAR)

P. 148

Answer 7

Documentation of each medication administered, the dosage, the route of administration, the time and date administered, and the name of the person administering the medication.

Question 8

Attending physician

P. 149

Answer 8

The Physician responsible for the care of the patient while hospitalized.

Question 9

Hospitalist

P. 149

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

P. 149

Answer 10

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

Question 11

Observation

P. 149

Answer 11

A patient status used when the patient’s condition does not warrant in inpatient level of care but does require observation by medical personnel. Observation typically lasts from 24 hours to know more than 48 hours.

Question 12

History of present illness (HPI)

P. 151

Answer 12

The symptoms or circumstances leading the patient to seek medical intervention.

Question 13

Review of systems (ROS)

P. 151

Answer 13

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

Question 14

Pathologist

P. 152

Answer 14

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

Question 15

Autopsy

P. 152

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)

P. 153

Answer 16

The unit to which a patient is transferred following surgery for monitoring of vital signs and condition post-surgery.

Question 17

Durable medical equipment (DME)

P. 156

Answer 17

Medical equipment meant to be used for long periods. Such as hospital beds, hearing aids, orthotics, and processes.

Question 18

Apgar score

P. 156

Answer 18

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

Question 19

Computerized physician order entry (CPOE)

P. 158

Answer 19

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

Question 20

Picture archiving and communication system (PACS)

P. 159

Answer 20

Digitizes Radiology film into computer images. X-ray film takes a great deal of valuable floor space for storage, disposal is expensive, and duplication is time-consuming and labor-intensive, should films be needed by another physician or facility. With a PACS, images are stored on an optical disc and easily duplicated or transferred to another provider of care

Question 21

Admission, discharge, and transfer ( ADT) system

P. 162

Answer 21

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

Question 22

Patient census

P. 162

Answer 22

The number of inpatients occupying beds at any given time.

Question 23

Bar code

P. 163

Answer 23

A machine readable code consisting of vertical parallel bars and white space. Every scan 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 location and encounter within the EHR.

Question 24

Point of care

P. 164

Answer 24

The physical location where a healthcare professional delivers services to a patient.

Question 25

Interface

P. 166

Answer 25

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

Question 26

Claims data

P. 166

Answer 26

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 10 codes.