the patient history and physical report begins with which of the following types of information?

What is the history component of a patient presentation?

The history component is comparable to telling a story and should include a beginning and some form of development to adequately describe the patient’s presenting problem.

How long does it take to enter information into the medical record?

However, organizations are expected to have a written policy (see RC.01.03.01) requiring timely entry of information into a medical record that does not exceed 30 days. A signature (authentication) is considered an ‘entry’.

How to make the majority of clinical history available to the physician?

How to make the majority of the clinical history available to the physician. Job opportunities should remain good for transcriptionists who are... certified Match the common transcribed report to content found within the report. patient's history of hospital admissions > discharge summary

What is required content in a patient education plan?

The required content is relevant and includes sufficient information necessary to provide the care, treatment and services required addressing the patient's condition, planned care and assessed needs. The specific content may vary based on services provided and patient population served by the care setting.

Which of the following information included in a patient's medical record is subjective information?

Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history.

Which of the following information should be excluded from a resume?

Things not to put on your resumeToo much information.A solid wall of text.Spelling mistakes and grammatical errors.Inaccuracies about your qualifications or experience.Unnecessary personal information.Your age.Negative comments about a former employer.Details about your hobbies and interests.More items...•

Which of the following information is considered demographic data?

Demographic information examples include: age, race, ethnicity, gender, marital status, income, education, and employment. You can easily and effectively collect these types of information with survey questions.

Which of the following computer terms is defined as an accumulation of data to be processed?

Which of the following computer terms is defined as "an accumulation of data to be processed"? Batch. The most widely used filing system for medical practices is called. Subject filing.

Which of the following is not necessary to include in your personal details?

6. Personal details. There's no need to include personal information on a resume such as your social security number, marital status, nationality, sexual orientation, or spiritual beliefs. In fact, it is illegal for employers to ask for these personal details.

What personal information should be on a resume?

You can include the following personal details to your resume:Name. This is usually right at the top of your resume in the largest font compared to all other text on the page. ... Phone number. ... Residential address. ... Email address. ... Personal website. ... Languages known. ... Reduce redundant information. ... Focus on relevant skills.

What are the type of demographic data?

Types of Demographic Information The common variables gathered in demographic research include age, sex, income level, race, employment, location, homeownership, and level of education. Demographical information makes certain generalizations about groups to identify customers.

Which of the following information provided by the patient on the patient registration form is considered to be demographic information?

RMA review test 2QuestionAnswerWhich of the following information provided on a patient registration form is demographic information?Patient's place of employmentThe appropriate route of administration of fluticasone (Advair) isInhalationThe following needle gauges most appropriate for performing a venipuncture is22176 more rows

What are the types of population data?

Population data contains various influential details such as birth, death, demographic information such as age, sex, annual income, occupation, language, etc. The overall socio-economic, economic, political, cultural progress of a country is dependent on population data to a large extent.

Which of the following is a form used to identify the number of withholding allowances chosen by an employee?

The Internal Revenue Service (IRS) Form W-4 is used to calculate and claim withholding allowances. The amount of withholding is based on a taxpayer's filing status: single or married but filing separately, married and filing jointly, or head of household, and the number of withholding allowances they claim.

Which of the following scheduling methods allows short term flexibility within an hour to account for variables in appointments?

Chapter 10QuestionAnswerTwo patients are scheduled for an appointment at the same time on the same day . This is example ofDouble bookingScheduling methods allow short term flexibility within an hour to account for variables in appointment ?WavesProvides confidentiality of patient informationNumeric67 more rows

When choosing a diagnosis code a medical assistant should consider which of the following actions in order to avoid an insurance denial?

1/2 to 5/8 inch needle, 25 gauge. When choosing a diagnosis code, a medical assistant should consider which of the following in order to avoid an insurance denial? Coding to the highest level of specificity.

What is the responsibility of the organized medical staff to determine the minimum required content of medical history and physical examinations?

It is the responsibility of the organized medical staff to determine the minimum required content of medical history and physical (H & P) examinations (see MS.03.01.01 EP 6). The required content is relevant and includes sufficient information necessary to provide the care, treatment and services required addressing the patient's condition, planned care and assessed needs.

What is the intent of a medical staff?

The intent is that the medical staff defines only certain circumstances, such as certain type of outpatient surgeries or procedures such as angiograms, that require a history and physical.

What is the meaning of MS.03.01.01 EP 11?

MS.03.01.01 EP 11 (HAP only) requires that "the organized medical staff defines the scope of the medical history and physical examination when required for non-inpatient services". The intent is that the medical staff defines only certain circumstances, such as certain type of outpatient surgeries or procedures such as angiograms, that require a history and physical.

Is a dictated history and physical not transcribed?

The mere existence of a dictated history and physical that has not been transcribed and entered in the patient's medical record is not in compliance with the intent of the requirements as essential information needed to further assess and manage the patient would not be available to the patient care team.

Can an organization have a policy that would permit the use of a history and physical examination performed by any practitioner?

The organization can have a policy that would permit the use of a history and physical examination performed by any practitioner permitted by state law. In this situation a practitioner who is privileged by the organization (see MS.03.01.01 EP 8), as permitted by state law and organization policy and familiar with the organization's policy for the defined minimal content of the history (see MS.03.01.01 EP 6) and physical must:

Can a medical student be a H&P?

A medical student has no legal status as a provider of health care services, therefore, a medical History and Physical (H&P) conducted by a medical student would not fulfill the requirements.

Can a dentist complete a history?

The medical staff must determine, based on state-specific law and regulation (Scope of Practice), the extent to which a Dentist or Podiatrist may complete a history and physical. Typically, the Dentist or Podiatrist is only authorized to perform aspects of the History and Physical that are applicable to either Dentistry or Podiatry.

How many levels of history are there in Medicare?

The Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines for Evaluation and Management Services have four history levels, each of which comprises four elements. 1 To qualify for a given history level, certain elements are required, as depicted in Table 1.

What is the difference between a detailed and a problem focused history?

For example, a problem-focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), while a detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS) and pertinent past, family and/or social history (PFSH).

Who must obtain HPI?

HPI includes information obtained from the patient and must be obtained by the provider or a qualified healthcare professional. Some Medicare carriers have established their own policies that require the provider to perform the work of the HPI.

What happens if a clear CC is not documented?

If a clear CC is not documented, the provider may be subject to a denial in the event of an audit and is usually referenced as not being medically necessity. History of Present Illness: The HPI is a chronological description of the patient’s symptoms or clinical problems from the onset and/or how it has developed.

What is the purpose of a patient history interview?

RATIONALE: During the patient history interview and physical examination, the nurse collects the necessary data to support the identification of nursing diagnoses and collaborative problems.

Why should an emergency assessment be performed?

A) An emergency assessment should be performed to ensure the patient's safety.

What is an assessment?

abbreviated assessment that focuses on 1 or more body systems that are the focus of care; includes assessment related to a specific problem like pneumonia or specific abnormal labs; monitors for signs of new problems; used to evaluate status of previously identified problems and monitor for signs of new problems.