The FIRST piece of documentation an inpatient should read is the _____.
A. discharge summary
B. history and physical
C. operative report
D. physician progress notes
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Q. 2) The patient's means of arrival is typically found in _____ documentation.
A. physician office
B. acute inpatient
C. emergency department
D. same-day surgery
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Q. 3) The following examination is for what body system? Head is normocephalic. TMs are clear. Oropharynx is unremarkable and neck is supple.
A. Nervous
B. Respiratory
C. HEENT
D. Musculoskeletal
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Q. 4) ____ Formal process to ensure appropriate level of service is performed in an efficient and cost-effective manner in the appropriate setting based on the patient's physical needs and quality of life.
Fill in the blank with correct word.
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Q. 5) If it isn't _____, it wasn't done.
A. medically necessary
B. documented
C. coded
D. diagnosed
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Q. 6) Which condition should be documented as to whether or NOT the condition is reducible?
A. Crush injury to the right hand
B. Pharyngitis with sinus infection
C. Cephalgia
D. Umbilical hernia
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Q. 7) _________ She has CHF, COPD, and OA, all which remain stable with her current treatments.
Fill in the blank with correct word.
(
Q. 8) ____ The advice of another physician or physicians regarding a patient's diagnosis or therapeutic options.
Fill in the blank with correct word.
(
Q. 9) The _____ is a primary source document from which current signs, symptoms, previous medical history, personal history, and family history is gathered.
A. history of present illness
B. physical examination
C. discharge summary
D. diagnostic report
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Q. 10) Showed no cyanosis, clubbing, or edema
Identify the portion of the medical record in which the following statements would MOST likely be found.
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