OST 248 Test 1 Questions And Answers With 100% Correct Answers
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Course
OST 248
Institution
OST 248
What document would be the best place to find information about the reason a patient presented for
treatment
and pertinent medical history?
-Discharge summary
-History and physical
-Consultation report
-Operative report - History and physical
Which of the following does not impact the conten...
OST 248 Test 1
What document would be the best place to find information about the reason a patient presented for
treatment
and pertinent medical history?
-Discharge summary
-History and physical
-Consultation report
-Operative report - History and physical
Which of the following does not impact the content or format of health record documentation?
-Paper records
-Electronic health records
-Type of healthcare setting
-Demographic information - Demographic information
What document would be the best place to find information about the morphology of a specimen that
was
removed during a surgical procedure?
-Operative report
-Consultation report
-Pathology report
-Discharge summary - Pathology report
Which of the following may be coded from documentation by a non-physician provider?
-Stage of a pressure ulcer
-Insulin dependence for diabetes
-Presence of a pressure ulcer
, -Diagnosis of obesity - Stage of a pressure ulcer
Which of the following items is not normally found on a facesheet?
-patient name
-demographic data
-name of anesthesiologist for surgical procedure
-account number - name of anesthesiologist for surgical procedure
ICD-10-PCS requires significant documentation of details for surgical procedures that are performed.
Where would
these details be located?
-Discharge summary
-Progress note
-Operative report
-Pathology report - Operative report
Which of the following non-physician healthcare professionals may document information in the record
that can
be used for coding body mass index or stage of a pressure ulcer?
-RN
-surgical technician
-social worker
-CNA - RN
A(n) ______ provides information about pre-operative diagnosis, post-operative diagnosis, of the
surgeon(s) who performed the procedure, type of anesthesia, name of the procedure, specimens sent to
pathology, and detailed narrative description of the procedure. - operative report
A(n) ______ will be on the record if the attending physician requests a specialist to see the patient. -
consultation report
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