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
Assessing Palpebral Conjunctiva, Patient Position
Measuring Patient Height
Brief Review of the History of Oligonucleotide Synthesis
Position of patient following seizure
Hypothetical Exchanges of Information within the Brain of a Patient with Visual Agnosia
Medical Hot Zone Entry Exclusion Criteria During Pre-Entry Check