Author Question: Review the following patient record entry, and determine in which report it would be documented. ... (Read 81 times)

Alygatorr01285 · **on:** Jul 12, 2018

Review the following patient record entry, and determine in which report it would be documented.

Skin

No jaundice, reveals pale, cool, moist surface

Chest

Respirations normal

Lungs

Clear on inspection, percussion, and auscultation

Abdomen

No tenderness, guarding, or rigidity

Extremities

No significant findings

Genitalia

Normal

Rectal

Deferred
A) chief complaint
B) history of present illness
C) physical examination
D) review of systems

Question 2

Sunny Valley Hospital has adopted the following patient record documentation guidelines:

1.

All entries should be documented and signed by the author.

2.

Complete only necessary entries on preprinted forms. Leave others blank.

3.

If other patient(s) are referenced in the record, document their name(s).

4.

All documentation should be entered in permanent black ink.

5.

Be sure to document specific information and to avoid vague entries.

Determine which guidelines must be revised because they do not reflect sound documentation practices.

A) 1 and 2
B) 1 and 4
C) 2 and 5
D) 2 and 3