Medical documentation - Study guides, Class notes & Summaries

Medical Billing and Coding Certificate Exam Already Passed Chief Complaint (element 1 of history) History of present illness, Review symptom, Past, Family, and Social history History Levels (Element 2 of history) and Examination Levels (Element 3 of History) Problem focused, expanded problem focused, detailed, Comprehensive Medical Decision Making Complexity Levels (element 4 of history) Straightforward, Low, Moderate, High straightforward Minimal diagnosis Minimal...

An unresponsive 2-year-old child was found by his mother with a bottle labeled "Elavil 50 mg" by his side. Which piece of information is important to obtain from his mother? A. The size of the medication bottle. B. The expiration date of the medication. C. The number of pills left in the bottle. D. The person for whom the medication was prescribe. -Answer C. The number of pills left in the bottle. A nurse providing crisis intervention to the family of a seriously ill child can best ke...

ATI RN Fundamentals Proctored Exam Questions & Answers, 2024/2025-A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to code...

TEST BANK FOR BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL NURSING, 15TH EDITION (HINKLE, 2022), ALL CHAPTERS ,ISBN 13; 978-1975163259, ISBN 10; 1975163257 GRADED A+ TEST BANK FOR BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL NURSING, 15TH EDITION (HINKLE, 2022), ALL CHAPTERS ,ISBN 13; 978-1975163259, ISBN 10; 1975163257 GRADED A+ Table of Contents Chapter 01 Professional Nursing Practice 2 Chapter 02 Medical-Surgical Nursing 17 Chapter 03 Health Education and Health Promotion 30...

Through what document does a hospital establish compliance standards? code of conduct What is the purpose OIG work plant? Identify Acceptable compliance programs in various provider setting If a Medicare patient is admitted on Friday, what services fall within the three-day DRG window rule? Non-diagnostic service provided on Tuesday through Friday What does a modifier allow a provider to do? Report a specific circumstance that affected a procedure or service without chan...

Horseshoe (U-Shaped) pattern of redness and telangiectasias on the neck - Polikiloderma Contraindication for microdermabrasion - Rosacea What is in a jessner's solution - 14% salicylic 14% lactic 14% resorcinol In an ethanol solvent base Medical term for dry - Asteatosis What type of exfoliation is microdermabrasion? - Mechanical When it comes to peels, what depth level is necessary to affect the papillary dermis? - Medium What is a mammoplasty - breast augmentation Mos...

DD Form 689 Individual sick call slip that initiates the sick call process Used for patient who requests or receives medical/dental evaluation or treatment at an Army Medical Treatment Facility (MTF) used as a means of communication between medical personnel and the patient's commander SF 600 Chronological Record of Medical Care form used to document the chronological record of the patient's treatment Should include: - Date and time of visit - Medical Treatment Facilit...

NHA CCMA PRACTICE TEST (ANSWERED) WITH COMPLETE VERIFIED SOLUTION (FALL 2023/2024) A medical assistant is preparing a patient who has congestive heart failure (CHF) for an examination by the provider. Which of the following manifestations should the assistant expect? A. Palpitations B. Headaches C. Chest pain D. Shortness of breath Shortness of breath When measuring a patient's respiratory rate, which of the following actions should a medical assistant take to ensure an accurate read...

Test Bank for Darby and Walsh Dental Hygiene 5e 5th Edition by Jennifer A Pieren, Denise M. Bowen. ISBN-13: 7192 Full Chapters test bank included Part 1: Conceptual Foundations 1. The Dental Hygiene Profession 2. Dental Hygiene Metaparadigm Concepts and Conceptual Models 3. Evidenced-Based Decision Making 4. Community Health 5. Sustainable Health Behavior Change 6. Cultural Competency in Healthcare 7. Legal and Ethical Decision Making 8. The Professional E-Portfolio Part 2: Preparati...

Which function allows coders to query health care providers for clarification during a patient's inpatient hospitalization? Concurrent coding Which data type exchange between facility and diagnostic lab can generate visual representation of trends in lab results over time? Fielded and Coded data Which report is the practice manager creating to assist the scheduling of staff? Production by provider report Which EHR tool documents a provider adding comments for increasing the speci...