HIM Quiz 3 Review Study Test 2024.

HIM Quiz 3 Review Study Test 2024. chief complaint, history of present illness, past medical history, social history, family history, review of current systems, medication list - correct answer Patient history should include what seven items: physical exam - correct answer This is an assessment of patient body systems to determine diagnosis. provisional, differential, preadmission testing - correct answer The physical exam should document a _______ diagnosis, which may include a ______ diagnosis. It should also summarize the results of ________. anesthesia record - correct answer Type of record that documents patient monitoring during administration of anesthetic agents. preoperative, anesthesia, preoperative, intraoperative, postoperative, recovery - correct answer The anesthesia record documents administration of _____ meds, ______ administration during the operation, ______, _______, and _____ evaluation of patient, and ______ of patient. operative record - correct answer Type of record that documents findings, procedures, and techniques associated with surgery. principal participants - correct answer Who are the individuals identified in an operative record? preoperative, postoperative, procedures, techniques, anesthesia, condition, all, findings - correct answer The operative record must indicate the _____ and ____ diagnosis, surgical _____ and _______, type of _______, the _____ of patient at ____ stages, and operative ______. pathology report - correct answer Type of record that assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that was expelled by the patient.