Test Bank For Textbook of Physical
Diagnosis History and Examination 7th
Edition Swartz | 9780323221481 | All
Chapters with Answers and Rationals
MEDICAL RECORD - answer-Is a chart that documents the patient's experiences in the
hospital from admission to discharge
PATIENT CONFIDENTIALITY - answer-Why can't you bring medical history?
REFERRAL TO OTHER HOSPITAL, COMANAGEMENT, SUBPOENA, ASK A COPY
BUT ONLY A PORTION - answer-When can you take out medical record?
ADMISSION TO DISCHARGE - answer-Medical Record is a chart that documents the
patient's experiences in the hospital from ___________________________________
PATIENT'S MEDICAL HISTORY, CURRENT CONDITIONS, DETAILED PLAN FOR
PATIENT CARE - answer-Medical records contain relevant information regarding the:
COMMUNICATE CLEARLY AND SUCCINCTLY - answer-The medical record's
purpose is to ________________________________________________ information
of statistical and observational value for all members of the health professional team.
CHARACTERISTICS OF AN ACCEPTABLE RECORD - answer-- Written consistently
- Without shortcuts
- Noninterpretive language
- Entries and signatures
- Date and time
- Clear, concise, and properly oriented
WRITTEN CONSISTENTLY, WITHOUT SHORTCUTS, NONINTERPRETIVE
LANGUAGE, ENTRIES AND SIGNATURES, DATE AND TIME, CLEAR CONCISE
PROPERLY ORIENTED - answer-Characteristics of an acceptable record:
ILLEGAL - answer-Erasing/Obliterating is considered
ADMISSION NOTES, PREOPERATIVE NOTES, OPERATIVE NOTES AND
POSTOPERATIVE ORDERS, PROGRESS NOTES, DISCHARGE NOTES - answer-
The medical record contains five major parts:
REASON FOR ADMISSION, ADMISSION HISTORY - answer-Admission notes contain:
Diagnosis History and Examination 7th
Edition Swartz | 9780323221481 | All
Chapters with Answers and Rationals
MEDICAL RECORD - answer-Is a chart that documents the patient's experiences in the
hospital from admission to discharge
PATIENT CONFIDENTIALITY - answer-Why can't you bring medical history?
REFERRAL TO OTHER HOSPITAL, COMANAGEMENT, SUBPOENA, ASK A COPY
BUT ONLY A PORTION - answer-When can you take out medical record?
ADMISSION TO DISCHARGE - answer-Medical Record is a chart that documents the
patient's experiences in the hospital from ___________________________________
PATIENT'S MEDICAL HISTORY, CURRENT CONDITIONS, DETAILED PLAN FOR
PATIENT CARE - answer-Medical records contain relevant information regarding the:
COMMUNICATE CLEARLY AND SUCCINCTLY - answer-The medical record's
purpose is to ________________________________________________ information
of statistical and observational value for all members of the health professional team.
CHARACTERISTICS OF AN ACCEPTABLE RECORD - answer-- Written consistently
- Without shortcuts
- Noninterpretive language
- Entries and signatures
- Date and time
- Clear, concise, and properly oriented
WRITTEN CONSISTENTLY, WITHOUT SHORTCUTS, NONINTERPRETIVE
LANGUAGE, ENTRIES AND SIGNATURES, DATE AND TIME, CLEAR CONCISE
PROPERLY ORIENTED - answer-Characteristics of an acceptable record:
ILLEGAL - answer-Erasing/Obliterating is considered
ADMISSION NOTES, PREOPERATIVE NOTES, OPERATIVE NOTES AND
POSTOPERATIVE ORDERS, PROGRESS NOTES, DISCHARGE NOTES - answer-
The medical record contains five major parts:
REASON FOR ADMISSION, ADMISSION HISTORY - answer-Admission notes contain:
