Domain 3 Exam .docx - Domain 3 Exam A final progress note...

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Domain 3 Exam A final progress note is appropriate as a discharge summary for a hospitalization in which the patient
When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document
Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital?
Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that
You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to
The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave
The Joint Commission requires that all medical records be completed within ___________ following patient discharge.
In your acute care facility it has become critical that up-to-date information regarding patients who are transferred to the oncology patient care unit be immediately sent to an outpatient scheduling system to facilitate outpatient appointments. This transfer of service can be obtained most readily from
A system of preferred terminology for naming disease processes is known as a
medical nomenclature. The first patient with cancer seen in your facility on January 1, 2018 was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is
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. They must also develop and use a process for
One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process?

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