Case Studies In Health Information Management
3rd Edition
ISBN: 9781337676908
Author: SCHNERING
Publisher: Cengage
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Who completes the health history and current reason for visit?
A Receptionist
B Nurse
C Provider
D Patient or patient representative
A/An ___ assess the patient at the time of discharge to determine the amount of progress the patient made made prior to stopping their therapy.
A request for a patient’s medical record is sent by fax to your office. The fax cover sheet contains the letterhead of a nearby medical facility. You do not recognize the name of the physician, fax number, or telephone number stated for the physician’s office. How do you respond to the request?
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- For this assignment, you are the RN who has cared for Olivia Jones on the overnight shift. You will be using the SBAR format to provide shift report to the oncoming day nurse. The day nurse will be taking Ms. Jones to the OR for an emergency C-section. Use the information from the vSim and the information below to compose the SBAR report. Including “Situation-Background-Assessment – Recommendations according to the rubric. You will formulate the report using information from the vSim and you may supplement with this data: Olivia Jones is a 23-year-old, single, African-American female, G1 P0000 at 36 0/7 weeks of gestation. She has been diagnosed with severe preeclampsia and is admitted to the labor and delivery unit for assessment and surveillance. The patients blood type is O+. The patient is negative for HIV and Hepatitis B. Pregnancy has been unremarkable until routine prenatal visit at 30 weeks with elevated blood pressure at 146/92 mm Hg, proteinuria, and developing mild…arrow_forwardA nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse cor-rectly verifies his identity by: a. Asking the patient his nameb. Reading the patient’s name on the sign over the bedc. Asking the patient’s roommate to verify his named. Asking, “Are you Mr. Brown?”arrow_forwardWhen the patient presents with a non life threatening issue, the provider is most likely to access the full electronic health record (EHR) to assess for A Patient history and allergies B Self pay status C Social Security number D Marital statusarrow_forward
- How are you going to manage this patient? (Provide a detailed care plan and include a full trauma assessment in sequential order)arrow_forwardThe nurse checks Mr. Johnson's admission orders and notes medication is ordered as needed for leg pain. Which step of the nursing process is involvedarrow_forwardPatient have the legal right to know the name of each person who has accessed their records. Agree or disagree?arrow_forward
- A PATIENT’S RECORD UNDERWENT REVIEW BECAUSE THE OUTPATIENT DIAGNOSIS ABOUT MULTIPLE INJURIES WAS UNCLEAR. WHO IS AUTHORIZED TO CLARIFY THE DIAGNOSIS? HEALTH CARE PROVIDER HIM SUPERVISOR INSURANCE COMPANY OUTPATIENT CODERarrow_forwardEmma Mastrangelo had a CT scan of the brain today because of recurrent migraines. Total charges are $720.50. Her benefits pay 90 percent of this procedure. The allowed amount is $462.60. What is the patient responsibility, discount amount, and the amount the carrier pays provider?arrow_forward
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