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Chapter 3 Test - Flashcards

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Class:MRIS 101 - Intro to Health Info Systems
Subject:Medical Record Infor Systems
University:Ferris State University
Term:Fall 2011
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What is Quantitative Analysis? A review of the health record to determine its completeness and accuracy.

What is Qualitative analysis? A review of the health record to ensure that standards are met and to determine the adequacy of entries document the quality of care.
What is source-oriented medical records (SOMR)? Documents are grouped together according to their point of origin. Example: labs with labs, radiology with radiology.
What are the advantages of SOMR? Very organized for each department to locate section for documentation and easy for adding loose papers.
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What are the disadvantages of SOMR? Cannot determine all the patient's problems and treatment quickly and must look in each area of the chart, which is timely.
What is problem oriented medical records (POMR)? It provides a systematic method of documentation to reflect the thinking of a physician.
What are the 4 sections of POMR? Database, problem list, initial plan, and progress notes.
What is a database in POMR? Documentation of patient's expression of his/her own words. Includes: chief complaint, present illness, social history, medical history, physical examination, and diagnostic test results.
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What is a problem list in POMR? Facilitates ongoing patient care management. Each problem is numbered, titled, and dated. As each problem is resolved it is marked off- usually dropped off list or resolved is written and dated behind. Examples: pneumonia, smoking, etc.
What is the initial plan in POMR? An overall roadmap for addressing each of the patients problems. Examples: treatments, IV antibiotics, consult on smoking risk factors, consult social services, etc.
What is the progress notes in POMR? Used to document how the patient's problems are being treated and how he/she is responding to treatment. Each note is preceded by the number/title of patient problem. Documented in SOAP format.
What is SOAP format? Subjective, objective, assessment, and plan.
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What are the advantages of SOAP format? Examining all of patients problems and good training tool for house staff.
What are the disadvantages of SOAP format? Requires addition training and takes a lot of time to complete.
What is integrated medical record? Arranged so that documentation from various sources is intermingled and follows strict chronological order. Advantages: easy to follow the course of the patient's diagnosis and treatment. Disadvantages: difficult to compare similar information.
What is clinical data? Documents the patient's medical condition, diagnosis and treatment, as well as the healthcare services provided in the format of forms within the health records. Examples: history and physical, progress notes, nursing notes, physician orders, reports of diagnostic and therapeutic procedures, consultation report, discharge summary, and patient instructions.
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What is administrative data? The demographics and financial information within the health records along with various consents and authorization forms related to the provision of care and the handling of confidential patient information. Examples: release of information forms, billing forms, and advance directives.
What is implied consent? The type of permission that is inferred when a patient voluntarily submits to treatment.
What is expressed consent? The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services.
What is consent for treatment? Legal permission given by a patient or a patients legal representative to a healthcare provider that allows the provider to administer care and/or treatment or to perform surgery and/or other medical procedures.
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What are advance directives? Written document that names the patient's choice of legal representative for healthcare purposes. The person designated by the patient is then empowered to make healthcare decisions on behalf of the patient in the even that the patient is no longer capable of expressing preferences. Example: living wills.
What is clinical information? Most important function of the acute care record. Physicians, surgeons, and nurses are the main authors of clinical documentation.
What is the face sheet? Displays the demographic and financial data.
What is admitting/provisional diagnosis? Why the patient is in the facility provided by the admitting physician.
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What is final diagnosis or principal diagnosis? The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. No abbreviations can be used with the final diagnosis-regulations govern.
What is medical history? A summary of the patients illness from his or her point of view. Information that is provided by the patient to the provider.
What is included in the medical history? Chief complaint, present illness, past medical history, social and personal history, family medical history, and review of systems.
What is chief complaint? Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words.
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What is present illness? Detailed chronological description of the development of the patient's illness, from the appearance of the first symptom to the present situation.
What is the past medical history? Summary of childhood and adult illnesses and conditions, such as infection diseases, pregnancies, allergies, drug sensitivities, accidents, operations, hospitalizations, and current medications.
What is social and personal history? Marital status, dietary, sleep and exercise patterns, use of coffee, tobacco, alcohol, and other drugs, occupation, home environment, daily routine, and cancer histories.
What is family medical history? Diseases among relatives in which heredity or contact might play a role, such as allergies, cancer, cardiovascular, endocrine, renal, and respiratory diseases.
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What is review of systems? Systemic inventory designed to uncover current or past subjective symptoms.
What is physical examination? Provides objective information on the patient's condition. Includes provisional/admitting or impression at the end of the report.
What is an interval note? Updated history in physical examination.
What is plan of action? Brief description of what the provider plans to do for the patient during the stay to determine the final diagnosis and best plan of care.
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What are physician orders? Instructions the physician gives to other healthcare professionals who actually perform diagnostic tests and treatments, administer medications, and provide specific services to the patients.
What are verbal or telephone orders? State law and medical staff rules specify which practitioners are allowed to accept and execute verbal and telephone orders.
What are standing or routine orders? Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure.
What are admission orders? First order in the chart filled out by the physician who is admitting the patient.
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What are progress notes? Clinical observations with a purpose of physicians, nurses, and other caregivers to create a chronological report of the patients condition and response to treatment during the stay of the patient.
What is included in progress notes? Findings of physical exam, observations of vital signs, including pain assessments, chronological record of patient's course, including response to treatment, results of lab and rad procedures with plans of action or follow up, requests for consultations and reason, records of patient and family education.
What are the types of progress notes? Admission notes, daily notes, integrated progress notes, nursing notes, and discharge notes.
What is an admission note? First note written once the patient is admitted to a specific unit. Gives a brief overview of patient and current conditions.
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What are daily notes? Progress notes are normally written daily by professionals but frequency can vary by patient condition.
What are integrated progress notes? All disciplines document on the same progress note but need to make sure the discipline is identified at the start of the note.
What is a discharge note? Final note written by physician that includes the condition on discharge, instructions related to diet, activity, medications, and follow up. Nursing will use for final discharge work up for patient prior to leaving facility.
What are consultation reports? Documents the clinical opinion of a physician other than the primary or attending physician. Requested by primary or attending normally documented in physician orders or progress notes. Based on consulting physician's exam of the patient and a review of the patient health record.
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What is included on the consultation report? Name of physician who requested and reason, date and time consult was done, pertinent findings, consultants opinion, diagnosis or impression, recommendations for diagnostic testing and treatment, and signature, credentials and specialty.
What is included in nursing documentation? Nursing assessments, care plans, clinical practice guidelines, case management reports, progress notes, medication records, flow charts, and transfer records.
What is included in a nursing assessment? Detailed report that captures another whole history, reason for being in the hospital, current and pas illnesses, cognitive status, functional status, psychosocial status, family history, nutritional status, drug allergies and sensitivities, and current medications.
What is included in a care plan? Initial assessment of patient and illnesses, statement of treatment goals based on patient's needs and diagnosis, description of the activities planned to meet the treatment goals, patient education goals, discharge planning goals, timing of periodic assessments to determine progress toward meeting the treatment goals, and indicators of the need for reassessing the plan to address the patient's response to treatment and/or development of complications.
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What are clinical practice guidelines? Step by step, knowledge based procedures designed to standardize clinical decision making.
What are clinical protocols? Specific instructions for performing clinical procedures established by authoritative bodies such as medical staff committees.
What are clinical pathways? Tools designed to coordinate multidisciplinary care planning for specific diagnoses and treatments.
What re case management reports? The process of ongoing and concurrent review performed to ensure the necessity and effectiveness of clinical services being provided to the patient.
Generated by Koofers.com
What are nursing progress notes? Provide a complete record of the patient's care and response to treatment and gives a complete picture. Vital signs are recorded ever 2 hours at minimum.
What is included in medication record? Date and time of each drug administered, name of the medication, form of administration, medications dosage and strength, and signed and dated by the person who administered the drug.
What is included in flow charts? Graphic illustrations of data and observations, used in addition to narrative progress notes, input/output patterns, blood glucose records, and pain assessments.
What is a transfer record? Records the patients movement from one hospital department to another.
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What are laboratory reports? Show clinical lab test findings and ordered by a physician.
What are imaging reports? Report generated by a radiologist with an interpretation that is stored in the health record and the films are normally stored in the radiology department. Ordered by a physician.
What is included in surgical services documentation? Consent for surgery, preoperative H&P, anesthesia evaluation and records, transfusion records, postoperative progress note, recovery room records, operative report, pathology report, implant records.
What is included in the pre-operative anesthesia evaluation? Collects information on patients medical history and current physical and emotional condition.
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What are the basis for the anesthesia plan? type to be used, addresses patients risk factors, allergies, current medications, any past anesthesia problems, and patient's general medical condition.
What is the post-operative anesthesia record? Description of any unusual events or complications that occurred during surgery and documents the patient's condition at the conclusion of surgery and after recovery from anesthesia.
What is included in transfusion records? Type and amount of blood products received, the source of the blood products, patients reactions to the transfusion.
What do post-operative progress notes indicate? Presence or absence of anesthesia complications or other post op abnormalities, vital signs, and general condition after surgery.
Generated by Koofers.com
What are discharge summary functions? Ensuring the continuity of future care by providing information to the patients primary care physician and any consulting physicians, providing information to support the activities of the medical staff review committee, and providing concise information that can be used to answer information requests from authorized individuals or entities.
What is included in the discharge summary? Concise account of the patient's illness, course of treatment, response to treatment and conditions at time the patient is discharged, located at the front of the chart behind the face sheet.
What are the required elements of discharge summary? reason for admission, princiapal and secondary diagnoses, significant findings from tests, exams, therapies, procedures, procedures performed and treatment rendered, patient condition at discharge, instructions to the patient and family for medications, physical activity, diet, follow up and patient teaching, disposition of patient, and signature of discharging physician who dictated or hand wrote the summary.
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 What is Quantitative Analysis?A review of the health record to determine its completeness and accuracy.

 What is Qualitative analysis?A review of the health record to ensure that standards are met and to determine the adequacy of entries document the quality of care.
 What is source-oriented medical records (SOMR)?Documents are grouped together according to their point of origin. Example: labs with labs, radiology with radiology.
 What are the advantages of SOMR?Very organized for each department to locate section for documentation and easy for adding loose papers.
 What are the disadvantages of SOMR?Cannot determine all the patient's problems and treatment quickly and must look in each area of the chart, which is timely.
 What is problem oriented medical records (POMR)?It provides a systematic method of documentation to reflect the thinking of a physician.
 What are the 4 sections of POMR?Database, problem list, initial plan, and progress notes.
 What is a database in POMR?Documentation of patient's expression of his/her own words. Includes: chief complaint, present illness, social history, medical history, physical examination, and diagnostic test results.
 What is a problem list in POMR?Facilitates ongoing patient care management. Each problem is numbered, titled, and dated. As each problem is resolved it is marked off- usually dropped off list or resolved is written and dated behind. Examples: pneumonia, smoking, etc.
 What is the initial plan in POMR?An overall roadmap for addressing each of the patients problems. Examples: treatments, IV antibiotics, consult on smoking risk factors, consult social services, etc.
 What is the progress notes in POMR?Used to document how the patient's problems are being treated and how he/she is responding to treatment. Each note is preceded by the number/title of patient problem. Documented in SOAP format.
 What is SOAP format?Subjective, objective, assessment, and plan.
 What are the advantages of SOAP format?Examining all of patients problems and good training tool for house staff.
 What are the disadvantages of SOAP format?Requires addition training and takes a lot of time to complete.
 What is integrated medical record?Arranged so that documentation from various sources is intermingled and follows strict chronological order. Advantages: easy to follow the course of the patient's diagnosis and treatment. Disadvantages: difficult to compare similar information.
 What is clinical data?Documents the patient's medical condition, diagnosis and treatment, as well as the healthcare services provided in the format of forms within the health records. Examples: history and physical, progress notes, nursing notes, physician orders, reports of diagnostic and therapeutic procedures, consultation report, discharge summary, and patient instructions.
 What is administrative data?The demographics and financial information within the health records along with various consents and authorization forms related to the provision of care and the handling of confidential patient information. Examples: release of information forms, billing forms, and advance directives.
 What is implied consent?The type of permission that is inferred when a patient voluntarily submits to treatment.
 What is expressed consent?The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services.
 What is consent for treatment?Legal permission given by a patient or a patients legal representative to a healthcare provider that allows the provider to administer care and/or treatment or to perform surgery and/or other medical procedures.
 What are advance directives?Written document that names the patient's choice of legal representative for healthcare purposes. The person designated by the patient is then empowered to make healthcare decisions on behalf of the patient in the even that the patient is no longer capable of expressing preferences. Example: living wills.
 What is clinical information?Most important function of the acute care record. Physicians, surgeons, and nurses are the main authors of clinical documentation.
 What is the face sheet?Displays the demographic and financial data.
 What is admitting/provisional diagnosis?Why the patient is in the facility provided by the admitting physician.
 What is final diagnosis or principal diagnosis?The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. No abbreviations can be used with the final diagnosis-regulations govern.
 What is medical history?A summary of the patients illness from his or her point of view. Information that is provided by the patient to the provider.
 What is included in the medical history?Chief complaint, present illness, past medical history, social and personal history, family medical history, and review of systems.
 What is chief complaint?Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words.
 What is present illness?Detailed chronological description of the development of the patient's illness, from the appearance of the first symptom to the present situation.
 What is the past medical history?Summary of childhood and adult illnesses and conditions, such as infection diseases, pregnancies, allergies, drug sensitivities, accidents, operations, hospitalizations, and current medications.
 What is social and personal history?Marital status, dietary, sleep and exercise patterns, use of coffee, tobacco, alcohol, and other drugs, occupation, home environment, daily routine, and cancer histories.
 What is family medical history?Diseases among relatives in which heredity or contact might play a role, such as allergies, cancer, cardiovascular, endocrine, renal, and respiratory diseases.
 What is review of systems?Systemic inventory designed to uncover current or past subjective symptoms.
 What is physical examination?Provides objective information on the patient's condition. Includes provisional/admitting or impression at the end of the report.
 What is an interval note?Updated history in physical examination.
 What is plan of action?Brief description of what the provider plans to do for the patient during the stay to determine the final diagnosis and best plan of care.
 What are physician orders?Instructions the physician gives to other healthcare professionals who actually perform diagnostic tests and treatments, administer medications, and provide specific services to the patients.
 What are verbal or telephone orders?State law and medical staff rules specify which practitioners are allowed to accept and execute verbal and telephone orders.
 What are standing or routine orders?Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure.
 What are admission orders?First order in the chart filled out by the physician who is admitting the patient.
 What are progress notes?Clinical observations with a purpose of physicians, nurses, and other caregivers to create a chronological report of the patients condition and response to treatment during the stay of the patient.
 What is included in progress notes?Findings of physical exam, observations of vital signs, including pain assessments, chronological record of patient's course, including response to treatment, results of lab and rad procedures with plans of action or follow up, requests for consultations and reason, records of patient and family education.
 What are the types of progress notes?Admission notes, daily notes, integrated progress notes, nursing notes, and discharge notes.
 What is an admission note?First note written once the patient is admitted to a specific unit. Gives a brief overview of patient and current conditions.
 What are daily notes?Progress notes are normally written daily by professionals but frequency can vary by patient condition.
 What are integrated progress notes?All disciplines document on the same progress note but need to make sure the discipline is identified at the start of the note.
 What is a discharge note?Final note written by physician that includes the condition on discharge, instructions related to diet, activity, medications, and follow up. Nursing will use for final discharge work up for patient prior to leaving facility.
 What are consultation reports?Documents the clinical opinion of a physician other than the primary or attending physician. Requested by primary or attending normally documented in physician orders or progress notes. Based on consulting physician's exam of the patient and a review of the patient health record.
 What is included on the consultation report?Name of physician who requested and reason, date and time consult was done, pertinent findings, consultants opinion, diagnosis or impression, recommendations for diagnostic testing and treatment, and signature, credentials and specialty.
 What is included in nursing documentation?Nursing assessments, care plans, clinical practice guidelines, case management reports, progress notes, medication records, flow charts, and transfer records.
 What is included in a nursing assessment?Detailed report that captures another whole history, reason for being in the hospital, current and pas illnesses, cognitive status, functional status, psychosocial status, family history, nutritional status, drug allergies and sensitivities, and current medications.
 What is included in a care plan?Initial assessment of patient and illnesses, statement of treatment goals based on patient's needs and diagnosis, description of the activities planned to meet the treatment goals, patient education goals, discharge planning goals, timing of periodic assessments to determine progress toward meeting the treatment goals, and indicators of the need for reassessing the plan to address the patient's response to treatment and/or development of complications.
 What are clinical practice guidelines?Step by step, knowledge based procedures designed to standardize clinical decision making.
 What are clinical protocols?Specific instructions for performing clinical procedures established by authoritative bodies such as medical staff committees.
 What are clinical pathways?Tools designed to coordinate multidisciplinary care planning for specific diagnoses and treatments.
 What re case management reports?The process of ongoing and concurrent review performed to ensure the necessity and effectiveness of clinical services being provided to the patient.
 What are nursing progress notes?Provide a complete record of the patient's care and response to treatment and gives a complete picture. Vital signs are recorded ever 2 hours at minimum.
 What is included in medication record?Date and time of each drug administered, name of the medication, form of administration, medications dosage and strength, and signed and dated by the person who administered the drug.
 What is included in flow charts?Graphic illustrations of data and observations, used in addition to narrative progress notes, input/output patterns, blood glucose records, and pain assessments.
 What is a transfer record?Records the patients movement from one hospital department to another.
 What are laboratory reports?Show clinical lab test findings and ordered by a physician.
 What are imaging reports?Report generated by a radiologist with an interpretation that is stored in the health record and the films are normally stored in the radiology department. Ordered by a physician.
 What is included in surgical services documentation?Consent for surgery, preoperative H&P, anesthesia evaluation and records, transfusion records, postoperative progress note, recovery room records, operative report, pathology report, implant records.
 What is included in the pre-operative anesthesia evaluation?Collects information on patients medical history and current physical and emotional condition.
 What are the basis for the anesthesia plan?type to be used, addresses patients risk factors, allergies, current medications, any past anesthesia problems, and patient's general medical condition.
 What is the post-operative anesthesia record?Description of any unusual events or complications that occurred during surgery and documents the patient's condition at the conclusion of surgery and after recovery from anesthesia.
 What is included in transfusion records?Type and amount of blood products received, the source of the blood products, patients reactions to the transfusion.
 What do post-operative progress notes indicate?Presence or absence of anesthesia complications or other post op abnormalities, vital signs, and general condition after surgery.
 What are discharge summary functions?Ensuring the continuity of future care by providing information to the patients primary care physician and any consulting physicians, providing information to support the activities of the medical staff review committee, and providing concise information that can be used to answer information requests from authorized individuals or entities.
 What is included in the discharge summary?Concise account of the patient's illness, course of treatment, response to treatment and conditions at time the patient is discharged, located at the front of the chart behind the face sheet.
 What are the required elements of discharge summary?reason for admission, princiapal and secondary diagnoses, significant findings from tests, exams, therapies, procedures, procedures performed and treatment rendered, patient condition at discharge, instructions to the patient and family for medications, physical activity, diet, follow up and patient teaching, disposition of patient, and signature of discharging physician who dictated or hand wrote the summary.
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