QUESTION: 93

Documentation found in acute care health records should include core measure quality indications required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for pneumonia patients is

beta blocker at discharge.
blood culture before first antibiotic received.
early administration of aspirin.
discharged on antithrombotic.

Answer(s): B

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QUESTION: 94

One record documentation requirement shared by BOTH ascute care and emergency departments is

patient's condition on discharge.
time and means of arrival.
advance directive.
problem list.

Answer(s): A

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QUESTION: 95

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

standing orders.
telephone orders.
stop orders.
discharge order.

Answer(s): D

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QUESTION: 96

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam, " you explain that the review of systems is used to document

objective symptoms observed by the physician.
past and current activities, such as smoking and drinking habits.
a chronological description of patient's present condition from time of onset to present.
subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.

Answer(s): D

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