acute care report contains physicians findings based on examination of patient

by Ms. Berniece Von 10 min read

CH.4 (quiz) - Health Record and Documentation . - HIM100C

35 hours ago Which of the following is not usually a component of acute care patient records? Problem List. ... Contains the physician's findings based on an examination of the patient? Physical exam. What is the function of a consultation report? >> Go To The Portal


What are the basic components of an acute care health record?

Four of the Basic Components of an Acute Care Health Record. Acute care is given, often in an emergency department, when a patient has a severe but usually brief illness or condition. The medical record of the patient, both as an in-patient and later as an out-patient, should be kept up to date and include a plan of care.

What is acute care?

Acute care is given, often in an emergency department, when a patient has a severe but usually brief illness or condition. The medical record of the patient, both as an in-patient and later as an out-patient, should be kept up to date and include a plan of care.

Which represents the attending physician's assessment of the patient's current health status?

Represents the attending physician's assessment of the patient's current health status? Physical Examination. Patient history questionnaires are most often used in: Ambulatory Care.

What document represents documentation of the patient’s current and past health status?

Represents documentation of the patient's current and past health status? Medical history. Contains the physician's findings based on an examination of the patient? Physical exam. What is the function of a consultation report?

Which of the following contains the physicians findings based on examination of the patient?

Which of the following contains the physician's findings based on an examination of the patient? A physical exam documents what the physician found during an evaluation of the patient's condition.

What is usually a component of acute care patient records?

Which of the following is usually a component of acute care patient records? Progress notes are typically found in an acute care patient record.

What information is included in a consultation report quizlet?

A consultation report is a narrative report of a clinical opinion that a patients condition by a practitioner other than primary physician. A report of the analysis of body specimens is known as diagnostic report. Medical impressions are conclusions drawn from an interpretation of data.

What is documented in an emergency care record?

TITLE: EMERGENCY ROOM RECORD PURPOSE: To provide a legal written record of medical/nursing care rendered and the patient's response to that care during his/her emergency room visit.

What does a medical report contain?

A structured format incorporating elements of background information, medical history, physical examination, specimens obtained, treatment provided and opinion is suggested.

What information should be included in a patient's medical records?

Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. If written correctly, notes will support the doctor about the correctness of treatment.

What type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care to stabilize the patient?

WGU BDV1 Mod 4 Health Data Management across the continuum (AHIMA C2V3)QuestionAnswerWhich type of health record contains information about care provided prior to arrival at a healthcare setting and documentaiton of care provided to stabilize the patient?Emergency Care76 more rows

What information is documented in a therapeutic service report?

Identification data, chief complaint, present illness, past history, family history, social history, review of systems.

What is a consultation report in medical terms?

Consultation reports are used to describe the patient's past history and the reason for being treated with a clear solution as well. The report will let the additional doctor know why the patient is there, in a brief report.

Which of the following is not usually documented in an emergency care record?

26 Cards in this SetChapter 3Content and Structure of the Health RecordWhich of the following materials is not documented in an emergency care record?patient's instructions at dischargeWhich of the following types of facility is not governed by Medicare long-term care documentation standards?assisted living facilities23 more rows

What type of information is recorded on the emergency department note?

The ED note should paint a picture of the encounter: how it began, how it evolved (and the factors that drove that evolution), how it comes to a conclusion, and where it needs to go in the future.

What are the documentation requirements for emergency department reports?

Good, clear ED charting is also critical for quality improvement reviews, research and utilization/risk management....Documentation comprises the following:Summary Statement – concise summary of the chief complaint along with main elements of the subjective and objective sections.Problem List – details of all problems.More items...•

What is an acute care record?

Acute care is given, often in an emergency department, when a patient has a severe but usually brief illness or condition. The medical record of the patient, both as an in-patient and later as an out-patient, should be kept up to date and include a plan of care.

When is acute care given?

Acute care is given, often in an emergency department, when a patient has a severe but usually brief illness or condition. The medical record of the patient, both as an in-patient and later as an out-patient, should be kept up to date and include a plan of care.

What is a nurse's note?

Nurses' Notes and Medication Records. The nurses care for the patient day to day and monitor progress or decline. They document this and their observations in the “Nurses’ Notes” or nursing progress notes. These records are maintained by licensed nursing staff.

What is a radiology record?

The record contains all radiologic findings, laboratory reports, surgical consultations and operative reports, pathology findings, special consultations and specialty care such as nuclear medicine or psychiatric interventions or observations. It contains records of all care and results of diagnostic procedures.

What is progress note?

The progress notes are an ongoing record of the treatments planned and initiated, and the patient’s response to each therapy. It includes an ongoing plan of care. When a specialist is consulted, he may send a complete report of his findings later, but the consultation visit is documented in the progress notes.

Who completes a history and physical?

The history and physical must be completed by the physician or his designee within a specific time. It will contain information and physical findings about past illnesses and injuries, and the specific condition which has brought the patient to the hospital.

Do nurse orders have to be written?

All physicians’ orders must be in writing and signed. If a nurse takes a verbal order from the doctor, it must be written on the physician’s orders record, reviewed and signed as with telephone orders .