Rhds Exam - Chapter 2 - Report Types

Front 1

NAME THE BASIC 4 REPORTS IN AN ACUTE CARE SETTING

Back 1

HISTORY & PHYSICAL
CONSULTATION
OPERATIVE REPORT
DISCHARGE SUMMARY

Front 2

Who sets the turnaround time for acute care facilities?

Back 2

Joint Commission PC.2.120

Front 3

What is the turnaround time for a physical examination?

Back 3

completed within 24 hours of admission

Front 4

What is the turnaround time for

HISTORY AND PHYSICAL EXAMINATION

Back 4

must have been completed 30 days before the patient is admitted or readmitted to the hospital

Front 5

What is the turnaround time for an

OPERATIVE PROCEDURE

Back 5

immediately after procedure

no Joint Commission TAT

Front 6

What is the turnaround time for

DISCHARGE SUMMARY

Back 6

completed within a period of time that will not exceed 30 days following discharge

Front 7

What is the turnaround time for an

AUTOPSY

Back 7

provisional anatomic diagnosis should be recorded in the medical record within 3 days; the complete report should be made part of the record within 60 days

Front 8

What is the turnaround time for a

CONSULTATION REPORT

Back 8

no set standard by Joint Commission

usually within 24 hours or less

Front 9

According to Delmar’s Medical Transcription Handbook, patients generally present themselves to a medical office in what 3 three instances?

Back 9

a workup visit

a checkup visit

a followup visit

Front 10

The term physical examination denotes a group of diagnostic observations and maneuvers performed directly on the patient’s body by the physician with only simple portable instruments to assist. Name the 4 techniques.

Back 10

inspection (looking),
palpation (feeling),
auscultation (listening),
percussion (tapping).

Front 11

Experts predict that because of its redundancy and repetition of information, the EHR will eliminate the need for which type of report, as all information will be housed and accessible within the patient’s EHR.

Back 11

DISCHARGE SUMMARY

Front 12

What type of report is generated when an attending physician requests an opinion from another care provider?

Back 12

CONSULTATION

Front 13

The report may contain the same basic components as a typical history and physical exam report, but will also include what additional headings?

Back 13

a main heading of “PLAN” or “RECOMMENDATION.”

Front 14

What is the purpose of date and time stamping in medical transcription?
a. To indicate the date treatment was provided
b. To identify the transcriptionist
c. To allow reimbursement
d. To help create an audit trail

Back 14

d. To help create an audit trail

Front 15

Which of the following has the shortest turnaround time (TAT)?
a. Discharge summary
b. Operative report
c. Consultation report
d. History and Physical

Back 15

b. Operative report

Front 16

Which of the following is similar to a History and Physical report?
a. Autopsy report
b. Emergency department visit report
c. Progress note
d. Discharge summary

Back 16

b. Emergency department visit report

Front 17

Which expression is included in the record to meet HIPAA security requirements?
a. Dictated by not read.
b. T1NXMX
c. T: 12/31/11, 1500
d. AXIS II

Back 17

c. T: 12/31/11, 1500

Front 18

Which section of a SOAP note gives details about the physical examination performed?
a. Assessment
b. Plan
c. Subjective
d. Objective

Back 18

d. Objective

Front 19

Which of the following sections of a History and Physical report includes the reason for the examination?
a. History of the Present Illness
b. Chief Complaint
c. Plan
d. Assessment

Back 19

b. Chief Complaint

Front 20

Which of the following is not typically dictated in the outpatient setting?
a. Phone call reports
b. SOAP notes
c. Medical correspondence
d. Progress notes

Back 20

d. Progress notes

Front 21

Which of the following types of reports is considered one of the "Basic Four?"
a. Pathology reports
b. Consultation reports
c. Emergency department visits
d. Autopsy reports

Back 21

b. Consultation reports

Front 22

Which of the following would not be considered medical office correspondence?
a. Letters of consultation
b. Medical excuses for travel
c. Phone call reports
d. Reminder letters to patients

Back 22

c. Phone call reports

Front 23

Which of the following would not be found in an autopsy report?
a. Medical history
b. Course of treatment
c. Plan
d. Macroscopic examination

Back 23

c. Plan

Front 24

Which of the following describes the length of time it takes to complete a report?
a. Turnaround time
b. Authorization time
c. Completion time
d. Finishing time

Back 24

a. Turnaround time

Front 25

Dictated reports in the outpatient care setting may also include what types of reports?

Back 25

SOAP notes
Medical correspondence
Phone call reports

Front 26

REGARDING AN H&P, NAME THE HEADING

The situation that brought the patient in to seek medical care

Back 26

CHIEF COMPLAINT

Front 27

REGARDING AN H&P, NAME THE HEADING

Nonmedical personal information that may have a bearing on patient’s health, ie, work history, home environment, etc

Back 27

SOCIAL HISTORY

Front 28

REGARDING AN H&P, NAME THE HEADING

Details leading up to the patient’s current status

Back 28

HISTORY OF THE PRESENT ILLNESS

Front 29

REGARDING AN H&P, NAME THE HEADING

Previous illnesses, injuries, surgeries, chronic diseases, allergies, and immunizations not discussed in the HPI

Back 29

GENERAL

Front 30

REGARDING AN H&P, NAME THE HEADING

Lifestyle regarding diet, sleep, exercise, caffeine, nicotine, alcohol, substance abuse, etc

Back 30

HABITS

Front 31

REGARDING AN H&P, NAME THE HEADING

A listing of symptoms by system

Back 31

REVIEW OF SYSTEMS

Front 32

REGARDING AN H&P, NAME THE HEADING

PMH

Back 32

PAST MEDICAL HISTORY

Front 33

REGARDING AN H&P, NAME THE HEADING

Inheritable or familial conditions and diseases

Back 33

FAMILY HISTORY

Front 34

REGARDING AN H&P, NAME THE HEADING

GENERAL APPEARANCE

Back 34

PHYSICAL EXAMINATION

Front 35

NAME THE TYPE OF REPORT:

All specimens sent to the pathology department for evaluation undergo a macroscopic examination (a “gross” description of what it looks like to the naked eye) and a microscopic examination (prepared and examined under the microscope). The final report includes the specimen type, clinical information, gross and microscopic descriptions, as well as the diagnosis.

Back 35

PATHOLOGY REPORT

Front 36

NAME THE TYPE OF REPORT:

components of the report may include:
• Medical history
• Course of treatment
• External examination
• Internal examination
• Evidence of injury
• Macroscopic examination
• Microscopic examination
• Gross findings (systems and organs)
• Special dissections
• Pathologic diagnosis
• Cause of death

Back 36

AUTOPSY REPORT or AUTOPSY PROTOCOL

Front 37

NAME THE TYPE OF REPORT:

Usually a brief report summarizing the patient’s visit. Components may include many of the same headings as in a history and physical exam, with the addition of sections regarding tests and procedures ordered, results, treatment, and plan for followup.

Back 37

EMERGENCY REPORT

Front 38

NAME THE TYPE OF REPORT:

reports to provide documentation of a conversation either with a patient or on the patient’s behalf.

Back 38

PHONE CALL REPORTS

Front 39

NAME THE TYPE OF REPORT:

A report of the findings and interpretation of the radiologist. The reports generally include the name of the study, a brief statement as to the clinical history of the patient, technique used, the findings, and the impression.

Back 39

RADIOLOGY REPORT