quizlet which report must be filed at the hospital before a patient may be admitted for surgery?

by Mylene Kunde 4 min read

Study 17 Terms | Chapter 2 Heath... Flashcards | Quizlet

4 hours ago The hospital must: All of the above. The use of restraints is permitted when: A medical order has been issued to restrain the patient. Patients have all of the following rights EXCEPT the right to: Be treated by a provider who is a member of their own faith. Care of a competent, communicative patient must … >> Go To The Portal


What information should be included in a surgery report?

-the name of the surgeon, title and date of procedure, the indications for surgery, and surgical findings (upon procedure being performed) -Includes a sponge count -Estimation of blood lost during the surgery

What are the two sections of a hospital report?

•Report is broken down into two sections: the history and the physical History of the Present Illness (HPI) Hospital Course Part of the discharge summary report; description of what transpired while the patient was in the hospital.

What should be included in a hospital admission report?

•Summation of what transpired during the patient's hospital admission •What the outcome or potential outcome of the hospitalization was or may be Final Diagnosis The name or names of the specific disease, syndrome or condition that ultimately led to the patient's hospitalization. Findings characteristics of the disease (often called signs) Format

What must the hospital do to restrain the patient?

The hospital must: A medical order has been issued to restrain the patient. Care of a competent, communicative patient must always be based on the presence of an advance directive in the chart or decisions listed in the directive. Which of the following statements is true?

What is the care of a competent communicative patient?

Care of a competent, communicative patient must always be based on the presence of an advance directive in the chart or decisions listed in the directive.

Do healthcare providers have to discuss no treatment?

Healthcare providers are required to discuss the option of no treatment with their patients.

Can a hospital restrict a visitor from seeing a patient?

Healthcare providers are required to discuss the option of no treatment with their patients. A hospital may restrict a visitor from seeing a patient if: The patient requests it. The provisions of HIPAA are designed to protect the patient's right to: Ensure the privacy and confidentiality of information.

Can medical records be shared with other providers?

A patient's medical records may be shared with other healthcare providers provided that: They are regulatory personnel investigating the facility's quality of care. All of the following statements are true EXCEPT: The consent form informs the patient that the experimental treatment may affect his or her regular care.

Do not resuscitate orders require a doctor's order?

A do-not-resuscitate (D NR) order does not require a doctor's order to go into effect.

Can a patient see medical information?

Provide the patient with information about the possible consequences of refusing treatment. Under certain circumstances, patients may not be allowed to see certain medical information. One of these circumstances occurs when the information in question is being inspected by an oversight board. True.

How long is an inpatient hospital?

a. An inpatient is a patient who is admitted to the hospital for at least 24 hours to receive extended medical care

What is an operation report?

Describes an operation or surgical procedure - a procedure both manual (using a physician's hands) and operative (using surgical tools or instruments) for the purpose of correcting, repairing, and diagnosing medical abnormalities, defects or diseases. -ususally dictated by the surgeon or by the assistant.

How long does it take to get a pathology report?

Such as radiology reports and pathology reports, usually have a turnaround time of 12 hours or less, as the report is probably required for other evaluation and treatment to be performed on the patient.

What is a pathology report?

The Pathology (PATH) report describes the pathological, or disease-related, findings of a sample tissue taken. The tissue samples can be taken during surgery, a biopsy, a special procedure, or an autopsy. The pathology report is dictated by the pathologist.

What is OP in medical terms?

what is sensed by the nose. Operative Note or Report (OP) Describes an operation or surgical procedure, both manual (using the physician's hands), and operative (using surgical tools or instruments) for the purpose of correcting, repairing and diagnosing medical abnormalities, defects or diseases. Report is usually dictated by ...

How many section headings are in a dismissal summary?

List six section headings contained in the dismissal summary:

How many reports are there in a basic report?

The basic six reports are combined with the previously listed "basic four," and combine to make six reports. The additional two reports are as follows:

What is the principal diagnosis?

The principal diagnosis is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital.

What is present on admission?

Present on admission is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

Can POA be reported on the basis of nursing documentation?

POA may be reported on the basis of nursing documentation.

Why deny a request for a patient's authorization?

A. Deny the request because you need the patient's authorization even if the daughter is the legal representative.

Why release information to the patient's daughter?

C. Release the information to the patient's daughter because she said she is his representative.

What is the HIPAA Privacy Rule?

The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to the least amount necessary to accomplish the intended purpose. What concept is this an example of?

Do all states have a health department?

All states have a health department with a division required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the public health department must be notified. Which of the following diseases would be reportable to the public health department?

Who performs autopsy in hospital?

Select all answers that apply: --There must be a consent for the autopsy (unless coroner's case). --The autopsy must be performed by a staff pathologist. --The autopsy report must be performed by a staff pathologist. --The tissue specimens must be filed in the hospital laboratory with the autopsy report.

How many deaths were there in July at Community Hospital?

Community Hospital had 275 discharges in July. There were six inpatient deaths. The hospital pathologist performed three of the autopsies. Also during this time, four outpatients died and two home health patients died and were brought to the hospital for autopsy.