Dr. Jones records the following information in the ____ section of a patient's SOAP note: BP is 120/74. Temperature is 100°F. Upon examination, lungs are clear but patient has nasal congestion
Sally Jones analyzes patient records and identifies several records without final diagnoses and procedures recorded on the face sheet. The type of analysis she performed is:
ABC Insurance has requested a copy of Sally Smith's inpatient record to reconcile the documentation in the record with a claim submitted by Sunny View Hospital for $200.00 of laboratory services and $325.00 of radiology services. Upon review of the record, ABC Insurance has determined that the laboratory report does not contain documentation for a laboratory test billed at $50.00. ABC Insurance
Ms. Smith analyzes patient records for deficiencies and determines that there are entries that have been authenticated using initials. She needs to identify the author of these entries to clarify information. She should reference the ____ to determine the full name of the author of the entries
Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie's attending physician. Who must sign the history and physical?
Dan Smith has recently moved to a new town. He calls Dr. Jones' office to make an appointment for an annual history and physical. It is the policy of Dr. Jones' office to have all new patients request information from their previous health care providers and forward copies to the office prior to their first visit. Dr. Jones reviews Dan's medical information, which includes treatment for alcohol
Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient's record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the ____ data recorded in the record
Sunny Valley Hospital has an electronic health record system. The health information management (HIM) department has been asked by the quality management department to monitor the number of times that providers make corrections in patient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions?
Sunny Valley Hospital uses the SOAP structure to document patient information. Observations about the patient would be documented in the ____ section of the progress note
Tom Smith, a patient at Sunny View Hospital, fell out of his bed during his inpatient admission. An incident report was completed at the time of the fall. Smith is suing the hospital because he feels that the nurses were negligent when caring for him. The following actions were taken by the facility. Determine which of these actions should not have occurred