Random
A chronological report of the patient's condition and response to treatment during a hospital stay is known as _____.
progress notes
This is located in the history and physical and is the patient's description of their symptoms or condition that brought them in for treatment
cheif complaint
This is included on each medical note to provide proof of authorship.
authentication
The resident states she has had abdominal pain for the past four days with nausea and vomiting this is an example of
subjective
When looking for missing patient identifiers, you are performing what?
Quantitative analysis
The agency that cares most about a facility's incomplete medical record is:
the JC
This is found in the history and physical and documents a complete exam of all of the patient's body systems. This exam requires procedures such as palpations, percussions, and auscultations. What type of exam is this?
Physical Examination
When is it ok for abbreviations to be used in medical documentation?
only when approved by medical staff
The resident's chest reveals normal rate and rhythm. The resident's longs are free of rales and crackles.
objective
When you are reviewing medical records for authentication, you are performing
Quantitative analysis
Which of the following is an example of an advance directive affected under the Patient Self Determination Act?
living will
This document will include who administered the medication and what time the medication was administered
MAR
When should medical record entries be documented?
as close as possible to the time of care delivery
The resident was diagnosed with abdominal pain of unknown etiology
Assessment
When you are reviewing a medical record for complete and consistent recordings of diagnostic statements, you are performing
Qualitative analysis
A patient is admitted for congestive heart failure and hypertension. During the admission, the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a ________.
comorbidity
The documentation on anesthetics administered, the dose and method of administration are reported here
anesthesia report
This is something that paper records must possess in order to be useful in care delivery and the continuum of care
legibility
The resident will be admitted for hydration concerns, and lab studies and scans will be performed
Plan
When you are reviewing a medical record for a clear description and justification for the course of the patient's hospitalization, you are performing
Qualitative analysis
Identify the documentation that records the attending physician's assessment of the patient's current health status.
physical exam
These documents include the face sheet, birth certificate, death certificate, informed consent, and advanced directives
Administrative documents
Documentation organized by nursing, physical therapy, dietary and social work is in what type of order
source-oriented
SOAP notes should be found in all provider ____
progress notes
QA helps identify ____ and ensures ____
deficiencies and ensures quality