HCMT 2325 Chapter #6 questions
answers graded A+
admission note - correct answer ✔✔Progress note documented by the attending physician at
the time of patient admission. The note features reason for admission including description of
patient's condition, brief history of present illness, patient care plan, method/mode of arrival,
patient's response to admission, and physical assessment.
advance directive - correct answer ✔✔Legal document that provides instructions as to how
patient want to be treated in the event they become very ill and there is no reasonable hope for
recovery.
Against Medical Advice (AMA) - correct answer ✔✔Patients who sign themselves out of a
facility and sign a release from responsibility for discharge.
ambulance report - correct answer ✔✔Generated by emergency medical technicians to
document clinical information such as vital signs, level of consciousness, appearance of the
patient, and so on. A copy of the ambulance report is placed in the emergency department
record; the original ambulance report is the property of the ambulance company.
ancillary service visit - correct answer ✔✔Appearance of an outpatient to a hospital
department to receive an ordered service, test, or procedure; also called occasion of service.
anesthesia record - correct answer ✔✔Required when a patient receives an anesthetic other
than a local anesthetic to document patient monitoring during administration of anesthetic
agents and other activities related to the surgical episode.
, antepartum record - correct answer ✔✔Generated in the physician's office and includes health
history of the mother, family and social history, pregnancy risk factors, care during pregnancy
including tests performed, and medications administered; also called prenatal record.
APGAR score components - correct answer ✔✔Measures a baby's appearance (A) (e.g., skin
color), pulse (P), grimace (G)(e.g., irritability), activity (A)(e.g.,, muscle tone and motion), and
respirations (R) on a scale of 1 to 10 (with up to 2 points assigned for each measurement and 10
being the maximum score).
attestation statement - correct answer ✔✔Signed by the attending physician to verify diagnoses
and procedures documented and coded at discharge of a hospital patient; discontinued in 1995.
autopsy - correct answer ✔✔An examination of the body after death usually with such
dissection as will expose the vital organs for determining the cause of death.
birth certificate - correct answer ✔✔Paperwork that must be filed for every live birth regardless
of where it occurred
birth history - correct answer ✔✔Documents summary of pregnancy, labor and delivery, and
newborn's condition at birth.
case management note - correct answer ✔✔Progress note documented by a case manager.
Outlines a discharge plan that includes case management/social services provided and patient
education.
certificate of birth - correct answer ✔✔Record of birth information about the newborn patient
and the parents, which identifies medical information regarding the pregnancy and birth of the
newborn; also called birth certificate.
certificate of death - correct answer ✔✔Contains a record of information regarding the
decedent, his or her family, cause of death, and the disposition of the body.
answers graded A+
admission note - correct answer ✔✔Progress note documented by the attending physician at
the time of patient admission. The note features reason for admission including description of
patient's condition, brief history of present illness, patient care plan, method/mode of arrival,
patient's response to admission, and physical assessment.
advance directive - correct answer ✔✔Legal document that provides instructions as to how
patient want to be treated in the event they become very ill and there is no reasonable hope for
recovery.
Against Medical Advice (AMA) - correct answer ✔✔Patients who sign themselves out of a
facility and sign a release from responsibility for discharge.
ambulance report - correct answer ✔✔Generated by emergency medical technicians to
document clinical information such as vital signs, level of consciousness, appearance of the
patient, and so on. A copy of the ambulance report is placed in the emergency department
record; the original ambulance report is the property of the ambulance company.
ancillary service visit - correct answer ✔✔Appearance of an outpatient to a hospital
department to receive an ordered service, test, or procedure; also called occasion of service.
anesthesia record - correct answer ✔✔Required when a patient receives an anesthetic other
than a local anesthetic to document patient monitoring during administration of anesthetic
agents and other activities related to the surgical episode.
, antepartum record - correct answer ✔✔Generated in the physician's office and includes health
history of the mother, family and social history, pregnancy risk factors, care during pregnancy
including tests performed, and medications administered; also called prenatal record.
APGAR score components - correct answer ✔✔Measures a baby's appearance (A) (e.g., skin
color), pulse (P), grimace (G)(e.g., irritability), activity (A)(e.g.,, muscle tone and motion), and
respirations (R) on a scale of 1 to 10 (with up to 2 points assigned for each measurement and 10
being the maximum score).
attestation statement - correct answer ✔✔Signed by the attending physician to verify diagnoses
and procedures documented and coded at discharge of a hospital patient; discontinued in 1995.
autopsy - correct answer ✔✔An examination of the body after death usually with such
dissection as will expose the vital organs for determining the cause of death.
birth certificate - correct answer ✔✔Paperwork that must be filed for every live birth regardless
of where it occurred
birth history - correct answer ✔✔Documents summary of pregnancy, labor and delivery, and
newborn's condition at birth.
case management note - correct answer ✔✔Progress note documented by a case manager.
Outlines a discharge plan that includes case management/social services provided and patient
education.
certificate of birth - correct answer ✔✔Record of birth information about the newborn patient
and the parents, which identifies medical information regarding the pregnancy and birth of the
newborn; also called birth certificate.
certificate of death - correct answer ✔✔Contains a record of information regarding the
decedent, his or her family, cause of death, and the disposition of the body.
