CRIS TEST | Questions and Answers with complete solution

Purposes of medical record - 1. To provide a communication tool between all healthcare providers. A physician, nurse, and any healthcare professional that treats the patient will complete documentation within the medical records 2. To provide documentation regarding diagnosis, treatment, and care of the patient while to find a receiving services from a healthcare facility. 3. To provide information needed for medical billing of services rendered to the patient and hospital financial management. 4. To provide a medium for analysis, study, and evaluation of the quality of care given to a patient. 5. To assist in protecting the legal rights of the patients, the healthcare facility, and other healthcare providers. A master patient index (MPI) - Tool gathered to obtain the complete medical record. (Is electronic medical database that holds information on every patient registered at a healthcare organization.) Discharge summary - Summary of treatment the patient received. Includes the diagnosis of their ailment. This is usually a transcribed report. history and physical - Reflects the history of the patients disease or injury, as well as the history of treatment. Usually transcribed, but may be hand written at the beginning of the progress notes. Electrocardiogram (EKG or ECG) & electroencephalogram (eeg) - These are specialized tests for the heart (EKG) and the brain (EEG) that produce strips of findings that may be mounted on individual pages. Pulmonary function test (PFT) - A test designed to measure how well the lungs are working usually found in the respiratory section. Operative report - This is a summary report of the operation including a description of what was done and the findings