Answers to Medical Records Lesson 5 Practice Quiz

1. Pull Deficiency Slips, Place slips in terminal digit order, Pull records, Pull easily found records first, Search records pulled for other physician, Document record not found, Ask physician intentions.

2. A box located in the Physician’s Incomplete Area where records are placed that the physician needs to complete.

3. Area where physicians go to work on incomplete records.

4. Attestation

5. Synopsis of patient’s treatment during an episode of care. Due 30 days after discharge.

6. Filed in chronological order by test type.

7. 24 hours

8. Daily report of patient diagnosis, treatment, and so on.

9. Consultation Report. Due 24 hours after consult.

10. Documentation of operation performed, preoperative diagnosis and postoperative diagnosis. Describes the surgeon’s findings from incision and ending with closure. Due 24 hours after the operation.

11. If the patient is admitted for the same condition within 30 days, an interim H&P may be written rather than preparing a new H&P. 12. Physician’s Order Form. Signed 24 hours after giving the order.

13. Form on which each caregiver, except physicians, records his/her initials and full signature and title. After profile is completed, the caregiver may initial documentation in the medical record.

14. Consent for surgery and anesthesia, operative report, preoperative preparation record, anesthesia report, pre and post anesthesia note, operating room clinical record.

15. Prenatal Records

16. Face Sheet

17. In chronological order by test type.

18. After the patient has been diagnosed with cancer, the cancer is staged by the surgeon or the oncologist, using the cancer staging form.

19. Pathology Report

20. To document the preoperative diagnosis, the postoperative diagnosis, the planned procedure, and the procedure or procedures actually performed. It lists all equipment used during the operation, sponge and instrument count, nurses involved in the surgery, date, time anesthesia was started, the operation start and end times, and the time anesthesia was ended.

21. History and Physical. Due 24 hours after admission. 22. Documents the circumstances of the transfer. The patient’s name, age, diagnosis, name and address of the facility receiving the patient and the reason for the transfer. Signatures hold the receiver of patient responsible.

23. Medication Administration Record