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
Measuring Patient Height
Patient Teaching
Example of problem focused patient
A medical assistant listening to the patient and physician discuss the patient's care.
Patient health history form Cont.