Documentation formats - Study guides, Class notes & Summaries

NHM 365 Exam 1: Review Questions and answers, VERIFIED/ Parts of the Medical Record • Demographics • MD orders (including diet order) • History and Physical (chief complaint) • Graphic Sheets (flow sheets) • Lab reports • Radiology Reports • Medication Records • Progress Notes: MD, Nursing, RD, Social Work, Therapists, etc. • Consultation Reports • Discharge Summary Progress Notes • Daily updates entered into the medical record • May be in SOAP, ADIME, nar...

BUAD 342 Exam 2 Latest Version Already Passed File-Oriented Processing Mandate a 1-to-1 relationship between programs and data files Data-Oriented Processing Create a single data repository to support numerous applications; a data pool is created and a variety of programs access needed data from the shared data pool Database Management System (DBMS) The resource available to define and manage data structures in an information system Relational Database Based on the theory of rel...

Ingrown Toenail correct answers painful condition in which the corner or side of a toenail grows into the soft flesh of that toe Define the term assessment in the context of the nursing process. correct answers "The registered nurse collects comprehensive data pertinent to the health care consumer's health and/or the situation. From class CBLO: Assessment refers to the systematic method of collecting and analyzing data for the purpose of planning patient-centered care"... Components of ...

CCA Exam Questions & Answers 2023/2024 An encounter that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n) - ANSWER-logic-based encoder The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the - ANSWER-CARF Manual You have been asked to give an example of a clinical information system. Which one of the following would you cite? A. Fina...

IAHSS Advanced Officer Certification 2024 Questions with 100% Correct Answers _____ % of customers stop doing business with an company because they are dissatisifed with the product or service. a. 10 % b. 14% c. 23% d. 31% - b. 14% ______ % of customers leave because of an attitude of indifference on the part of the service provider. a. 25% b. 50% c. 68% d. 75% - c. 68% ______ is an element in improving customer service: a. Identifying customers b. Attitude c....

CPMA Practice test with complete solutions In evaluation and management services, what does the A stand for in SOAP? What is included in this section? - Correct ️️ Assessment with diagnosis You are performing an audit of evaluation and management services for a family practice office. In the encounter, you read the physician order and reviewed a differential WBC. Which of the following best describes what you would expect to see in the medical record? - Correct ️️ Patient identific...

True & False The objective of SOL performance tuning on the client side is to generate an SOL query that returns the correct answer in the least amount of time, using the maximum amount of resources on the server side All database transactions must display at least the properties of Atomicity, consistency, convenience, and isolation Database recovery techniques are based on the isolation transaction property which indicate that the data used during execution of a transaction cannot...

5/3/19 ATI FUNDAMENTALS EXAM 1. CHAPTER 1: HEALTH CARE DELIVERY SYSTEMS A. Components of Health care systems a. Participants 1. Consumers- clients 2. Providers a. Licensed providers: registered nurses, license practical (or vocational) nurses (LPN), advanced practice nurses (APN), medical doctors, pharmacists, dentists, dietitians, physical/respiratory/occupational therapists, etc b. Unlicensed providers: assistive personal b. Settings 1. Hospitals, homes, skilled nursing, assisted living, schoo...

The National Practitioner Data Bank (NPDB) was established by the correct answers Health Care Quality Improvement Act Hospital reimbursement based on a retrospective payment system that issues payment based on daily charges is called correct answers per diem. An Internet-based third-party entity that manages and distributes software-based services across a WAN from a central data center is known as a(n) ____ provider correct answers application service Which is an example of clinical da...

client documentation correct answers -IF IT IS NOT WRITTEN DOWN IT DIDN'T HAPPEN - includes: assessmtn summaries, treatment to program plans, progress notes, discharge/referral summaries -document connections between program goals, client goals and client program involvement and client outcomes -in all cases, documentation and written records should focus on client behavior, rather than the specialists perceptions or guesses -in each case, the specialist is responsible for selecting the mso...