Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients?ĭ. nurses using bedside terminals to record vital signs. using occurrence screens to identify adverse events.ĭ. using an automated tracking system to locate a record.Ĭ. doctors using voice recognition systems to dictate radiology reports.ī. The best example of point-of-care service and documentation isĪ. Which secondary data source could be used to quickly gather this information?ĭ. You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Using the SOAP method of recording progress notes, which entry would most likely include a differential diagnosis?ĭ. According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations would most likely be prohibited?ĭ. apprising the patient of all complications that might occur. including the surgeon in the preanesthesia assessment.ĭ. including the primary caregiver in surgery consults.Ĭ. They must also develop and use a process forī. As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as x-rays or medical records are available. The foundation for communicating all patient care goals in long-term care settings is theĭ. Ultimate responsibility for the quality and completion of entries in patient health records belongs to theĭ. adverse effects and contraindications of drugs utilized during hospitalization.ĭ. quality of care through the use of preestablished criteria.Ĭ. The performance of qualitative analysis is an important tool in ensuring data quality.
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