Chapter 5 – Answer Key – Worksheets

Face Sheet, Patient Assessment & Reassessment, History, Physical

Examination, Admission/Discharge Record
Admission/Discharge Record 1. “Face Sheet” is also known as:

Clinical, Demographic, and 2. The face sheet contains three types of information. Name
Financial them.

Patient Name, Address, 3. Identify 4 common data elements collected on the face sheet.
Phone Number, etc.
Insurance Company Name,
Policy Number, etc.

History 4. The chief complaint is documented on the:

Provisional Diagnosis 5. The physician uses the above to establish the _____
diagnosis.

Review of Systems 6. The physician's assessment of all body systems is called the:

30 days 7. According to the JCAHO, a physician's office history can be

copied and placed on an inpatient record if it dated within
_____ of admission.

General (includes vital signs) 8. List three contents of a physical exam report.
HEENT, Chest, etc., Lab Data,
Plan for Admission,
Impression, etc.

24 9. According to the JCAHO, the physical exam is to be completed

within the first _____hours of admission to the hospital

Interval 10. When a patient is readmitted within 30 days for the same or a
related problem, which type of physical examination can be
written?

Comorbidity 11. A coexisting condition is a(n):

Complication 12. A condition which occurs during the hospitalization is the:

Physician’s Orders & Progress Notes

To direct the patient's care 13. What is the function of physician's orders?
during the hospitalization

Standing Orders 14. Name the type of orders physicians utilize for routine patient
care.
Discharge Order 15. Which order is written to release the patient from the facility?

Against Medical Advice 16. The patient who leaves the facility against express physician
(AMA) orders leaves:

Telephone (Phone) 17. Physicians are required to sign verbal orders within 24 hours
after they have been recorded in the patient's record. What
other types of orders must be signed within 24 hours of being
recorded?

Communication 18. What do progress notes serve as among members of the

health care team?

Integrated 19. When ancillary professionals document on the same progress

notes as physicians, what are these type of progress notes
called?

Discharge Note 20. Physician progress notes should include an admission note,
follow-up progress notes and:

Admission 21. The admission note summarizes the general condition of the
patient at the time of:

Condition 22. Follow-up progress notes are to be written as frequently as

required by the patient's:

TRUE 23. If the patient dies while in the hospital, the physician must still
document a final progress note. TRUE or FALSE.

Consultation Reports
Opinion 24. The consultation report documents services rendered by a
physician whose ____ is requested.

Attending Physician 25. Who is responsible for ordering a consultation?

(1) Patient whose diagnosis 26. Provide two examples of a patient who would need to have a
is unclear. (2) Patient who consultation ordered.
needs medical clearance for
surgery, etc.

Documentation that record 27. Name four of the content items that the consultation report
was reviewed, physical should contain.
examination of patient,
opinion, and
recommendations
Laboratory and Radiology Reports, and Nursing Documentation
Laboratory Report 28. Which report involves the examination of materials, fluid and
tissues obtained from patients to aid in diagnosis and
treatment?

Nuclear Medicine Imaging 29. Which report describes diagnostic studies and therapeutic
Report procedures performed using radiopharmaceutical agents?

Radiographic (X-ray) Report 30. Which report documents the interpretation of fluoroscopic
diagnostic services.

Attending Physician or 31. Who orders diagnostic studies?

Consulting Physician

FALSE 32. If a laboratory report is performed by an outside laboratory

(i.e., MDS of Olean), the original report is housed at the
outside laboratory and a copy of the report is placed on the
patient's record. TRUE or FALSE

Radiologist 33. Radiologic reports are signed by the and filed in the
24 Hours patient's record within:

5 years 34. The AOA/Conditions of Participation require Nuclear Medicine

Reports be retained for how many years?

Dosage 35. When radiopharmaceutical agents are utilized to perform a

test, the agent, date and _____ of the radiopharmaceutical are
to be documented in the report.

Technologist 36. The professionals responsible for signing the laboratory report
include the bacteriologist or _____ who performed the test.

Nurses Notes 37. Which report "describes nursing observations of the patient,
care and treatment given, and the patient's response to
treatment"?

Assessment/evaluation, 38. State three of the six elements required in the nursing process
nursing diagnosis, nursing of documenting patient care.
care provided, discharge
preparations, nursing
interventions

Graphic Sheet 39. Which provides for the nursing documentation of vital signs?

TPR 40. What is the abbreviation for "temperature, pulse and

respiration"?

MAR (medication 41. Medications administered orally, topically, by injection,

administration record) inhalation or infusion are documented on the:
Nutrition Notes & Consent Forms
Dietary Technician 42. The qualified dietitian or authorized designee is responsible for
documenting observations in the health record. Give an
example of the "authorized designee."

Progress Notes 43. In which report would the dietitian document information
pertaining to a patient's dietary needs?

TRUE 44. The JCAHO requires diet orders to be recorded in the patient's
record prior to serving the diet to the patient. TRUE or FALSE.

Battery 45. If a patient undergoes treatment without having signed a

consent form, this is considered "unlawful touching" and is
called _____.

Liability 46. If the patient is not required to sign a consent form prior to
treatment, this may result in _____ on the part of the facility.

Informed Consent 47. The patient or representative should indicate in writing that
(s)he has been informed of the nature of the treatment, risks,
complications, alternate treatments and consequences of
treatment. This is called:

Operative Report, Anesthesia Record, Recovery Room Record and

Pathology Report
Operative Report 48. The "operating room report" is also known as the:

Timely 49. Documentation of surgical procedures must be complete and:

TRUE 50. An operative record must be created for each procedure or

operation performed in the surgical suite. TRUE or FALSE.

Progress Note 51. When there is a transcription delay, the Joint Commission
requires the surgeon to document an operative:

Condition of patient, unusual 52. List 3 surgical items documented on the operating room report.
events, operative findings,
specimens removed,
procedure performed,
preop/postop dx

Preoperative Medications 53. The anesthesia record documents anesthetic agents

administered during the operation and:

Evaluation of patient's 54. State 3 items documented on the preanesthetic evaluation.

physical status, diagnostic
study results, choice of
anesthesia, procedure to be
performed, potential
anesthesia problems
Anesthesia Record (as well 55. Prior to induction of anesthesia, the patient's record indicates
as the MAR) time and dosage of administration of preanesthesia
medication. This is documented in doctor's orders and on the:

Progress Notes 56. In addition, the appraisal of any changes in the patient's
condition would be documented in:

Unusual events, anesthesia 57. List 3 items documented on the anesthesia record.
techniques used, anesthetic
agents administration, other
drugs administered, IV fluids,
blood/blood components
administered

Surgeon 58. Which physician documents the order releasing a patient from
the recovery room?

Complications (if any), 59. List 3 items documented in the postanesthesia note.
abnormalities (if any), date,
time, swallowing reflex,
cyanosis (if any), patient's
condition

Transfusion Record, Rehabilitation Reports, and Respiratory Therapy

Notes
TRUE 60. The JCAHO requires that records be maintained that detail the
receipt and disposition of all blood products. TRUE or FALSE

Administration 61. The transfusion record contains patient ID, blood group/Rh of
patient/donor, crossmatching, donor's ID #, and the record of
of the transfusion.

Physical therapy, 62. List three examples of rehabilitation services.

occupational therapy,
vocational/rehabilitative
services, psychiatric
services, prosthetic/orthotic
services, audiology, speech
pathology, etc.

TRUE 63. Special rehabilitation services are provided only upon

physician order. TRUE or FALSE

Monthly (timely) 64. The "assessment of physical rehabilitation achievements and

estimates of further rehabilitation potential" is to be
documented at least ____.

Inhalation Therapy 65. Respiratory therapy is also known as _____.

IPPB, etc. 66. List one example of a respiratory therapy that would be
administered to the patient.

TRUE 67. The JCAHO requires a "written prescription" for respiratory

 therapy. This means that the therapy is administered only
upon physician's order. TRUE or FALSE

Discharge Summary, Autopsy Report, Emergency Department Record

Clinical Resume 68. The discharge summary is known as the discharge abstract or:

Requests for information 69. The discharge summary contains information for continuity of
(e.g., from other hospitals or care, to facilitate medical staff committee review, and to
an insurance company respond to:

48 70. The JCAHO requires documentation of a discharge summary

on all cases except problems of a minor nature and those that
require less than hours of hospitalization.

Reason for hospitalization 71. The discharge summary includes a brief clinical statement of
the chief complaint and history of present illness. This is called
the:

Instructions 72. The physician documents the medications that the patient is to
take after discharge in the section of the discharge
summary.

Attending physician 73. Who signs the discharge summary?

Events 74. If the patient dies, a summation statement is added that

indicates reason for admission, findings during hospitalization,
hospital course, and ____ leading to death.

Necropsy 75. The autopsy report is a.k.a. postmortem examination or:

3 76. The JCAHO states that the autopsy provisional anatomic

diagnoses are to be recorded in the medical record within how
60
many days, and the complete protocol is to be made part of
the record within how many days?

Urgent 77. The ED record describes the evaluation and management of

patients who come to the hospital emergency department for
immediate attention of medical conditions/traumatic injuries.

TRUE 78. If a patient is admitted through the ED, the original ED record
is placed on the inpatient record. TRUE/FALSE

ER Physician 79. Who is responsible for authenticating the emergency record?

COBRA of 1986 80. Which law prevents hospitals from "dumping their indigent
patients on other institutions"?

Risk/benefits of transfer, 81. State one criterion that the physician documents in the
phone conversations re: emergency record about the transfer or the screening exam.
patient's condition, patient
request for transfer, patient's
condition upon transfer,
physician recommendation
for transfer

© Thomson Delmar Learning

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without prior written permission of the copyright owner.