Table of Contents
- 1 What is the progress note and what information would be found there?
- 2 Which two major types of data are contained in the health record?
- 3 What term is used to describe the process of making written entries about a patient in the medical record group of answer choices?
- 4 What is a progress report in nursing?
- 5 Which type of report is usually dictated while the physician is performing an examination on tissue and is often needed immediately by a second physician?
- 6 How are the EHR reports used to manage the health care facility?
- 7 What is the function of a consultation report?
- 8 What information is included in the patient’s current and prior health status?
What is the progress note and what information would be found there?
Progress notes usually contain information regarding the “progress” that the patient is making. Response to testing, treatment, and medications should be recorded. More importantly, on an ongoing basis, the attending physician should provide documentation regarding the patient’s diagnoses.
Which two major types of data are contained in the health record?
The health record generally contains two types of data: clinical and administrative. Clinical data document the patient’s medical condition, diagnosis, and treatment as well as the healthcare services provided.
What term is used to describe the process of making written entries about a patient in the medical record group of answer choices?
What term is used to describe the process of making written entries about a patient in the medical record? CHARTING!
Which of the following contains the physician’s findings based on an examination of the patient?
Medical history. Contains the physician’s findings based on an examination of the patient? Physical exam.
What is your chief complaint?
The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. In some instances, the nature of a patient’s chief complaint may determine if services are covered by health insurance.
What is a progress report in nursing?
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient’s clinical status or achievements during the course of a hospitalization or over the course of outpatient care.
Which type of report is usually dictated while the physician is performing an examination on tissue and is often needed immediately by a second physician?
The Pathology (PATH) report describes the pathological, or disease-related, findings of a sample tissue taken. The tissue samples can be taken during surgery, a biopsy, a special procedure, or an autopsy. The pathology report is dictated by the pathologist.
How are the EHR reports used to manage the health care facility?
An EHR is an electronic system used and maintained by healthcare systems to collect and store patients’ medical information. EHRs are used across clinical care and healthcare administration to capture a variety of medical information from individual patients over time, as well as to manage clinical workflows.
What type of report contains the result of the analysis of body specimens?
A pathology report is a document that contains the diagnosis determined by examining cells and tissues under a microscope. The report may also contain information about the size, shape, and appearance of a specimen as it looks to the naked eye.
What is the purpose of a laboratory report Chapter 38?
What is the purpose of a laboratory report? A laboratory report documents the results of any laboratory test performed on patient specimens.
What is the function of a consultation report?
What is the function of a consultation report? Document opinions about the patients condition from the perspective of a physician not previously involved in the patients care.
What information is included in the patient’s current and prior health status?
The past health section includes the patient’s past illness and treatment and this is where the nurse records information about a prior vaccination. Present health includes the current health status of the patient.