Review the following patient record entry, and determine in which ...

[Alygatorr01285]

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

[wergv]

Answer to Question 1

C

Answer to Question 2

D

[Alygatorr01285]

Excellent

[shailee]

YES! Correct, THANKS for helping me on my review