A patient was admitted with chronic obstructive pulmonary disease (COPD) on April 15 (this year). The patient has an exacerbation of COPD and was readmitted on June 1 (this year). The physician needs to document a(n):
A) history and physical examination
B) interval history and physical examination
C) progress note discussing patient's condition since April 15
D) short form history and physical examination
Question 2
As Ms. RHIT assembles and analyzes a discharged obstetrical patient's record, she finds the forms listed below. Which should be pulled from the discharged patient's record?
Face sheet
Admission history and physical exam
Consents
Patient's property record
Insurance claim
Laboratory reports
Antepartum record (copy)
Labor and delivery record
Incident report
Postpartum record
A) antepartum record (copy)
B) antepartum record (copy), insurance claim, and incident report
C) incident report and antepartum record (copy)
D) incident report and insurance claim
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