HIM 103 CHAPTER 6 EXAM QUESTIONS
AND ANSWERS ALL CORRECT
Which report describes the gross findings, organs examined, and techniques associated
with the performance of surgery? - Answer- Operative Record
Which report is documented by the individual qualified to administer anesthesia? -
Answer- Anesthesia Record
Secondary procedures are procedures performed during inpatient admission in addition
to the _______ procedure. - Answer- principal
A legal document in which the patient states the kind of health care they do or do not
want under certain circumstances is known as - Answer- Living Will
The discharge summary includes all the following except - Answer- emergency records
An interval history documents a patient's history of present illness and any pertinent
changes and physical findings that occurred since a previous inpatient admission if the
patient is readmitted within _____ days after discharge for the same condition. -
Answer- 10
The patient's description of their medical condition, stated in the patient's own words is
known as - Answer- Chief Complaint (CC)
An inventory by systems to document subjective symptoms stated by the patient is
known as - Answer- Review of systems
The physician orders by the medical staff which direct the continual administration of
specific activities for a specific period of time as a part of diagnostic or therapeutic care
are known as ___________ orders. - Answer- standing
The record that contains an antepartum record, labor and delivery record, and
postpartum record is known as the _______ record. - Answer- obstetric
The anesthesia record documents the monitoring of the patient during the
administration of the _______. - Answer- anesthetic agent
The operative report contains both the _______ and _______ diagnoses. - Answer-
preoperative, postoperative
AND ANSWERS ALL CORRECT
Which report describes the gross findings, organs examined, and techniques associated
with the performance of surgery? - Answer- Operative Record
Which report is documented by the individual qualified to administer anesthesia? -
Answer- Anesthesia Record
Secondary procedures are procedures performed during inpatient admission in addition
to the _______ procedure. - Answer- principal
A legal document in which the patient states the kind of health care they do or do not
want under certain circumstances is known as - Answer- Living Will
The discharge summary includes all the following except - Answer- emergency records
An interval history documents a patient's history of present illness and any pertinent
changes and physical findings that occurred since a previous inpatient admission if the
patient is readmitted within _____ days after discharge for the same condition. -
Answer- 10
The patient's description of their medical condition, stated in the patient's own words is
known as - Answer- Chief Complaint (CC)
An inventory by systems to document subjective symptoms stated by the patient is
known as - Answer- Review of systems
The physician orders by the medical staff which direct the continual administration of
specific activities for a specific period of time as a part of diagnostic or therapeutic care
are known as ___________ orders. - Answer- standing
The record that contains an antepartum record, labor and delivery record, and
postpartum record is known as the _______ record. - Answer- obstetric
The anesthesia record documents the monitoring of the patient during the
administration of the _______. - Answer- anesthetic agent
The operative report contains both the _______ and _______ diagnoses. - Answer-
preoperative, postoperative
