chp.11 Flashcards
The assessment portion of the medical records helps to document the evaluation of the patient to ___________________________________________________.
form a diagnosis or plan of treatment.
The primary purpose of medical documentation is to help health professionals __________________________________________________________.
communicating with other health professionals and describe a patient’s current state/history.
Physician’s _____________ consist of directives for tests, treatments, medications, and follow-up care.
orders
T/F: A patient’s medical record is considered a legal record of their medical history and health care.
T
A flow sheet contains a graphic record of a patient’s __________________.
vital signs
Progress notes that record information in a paragraph style use a ________________ format.
narrative
An ____________ sheet includes demographic data and insurance information provided by the patient prior to receiving care.
admission
Military time is based on a _____ hour cycle.
24
Most health care facilities have converted from paper records to which format?
Electronic
What are the benefits of using electronic physician’s orders?
fewer errors due to lost paperwork or misread orders
What is the purpose of progress notes?
To record every contact a provider has with a patient
Why is a family history included in the patient’s history?
certain disorders and diseases are inherited
T/F: Health care facility quality assurance efforts include the review of patient medical records.
T
What is a problem-oriented medical record?
type of medical record that organizes information according to the patient’s symptoms or complaint(s)
What is objective data in a medical record as opposed to subjective data?
data in the medical record that documents observations of the patient made by the health care provider
