When charting, you should avoid using words that can be interpreted to reflect your own ________.
Fill in the blank(s) with the appropriate word(s).
opinion
Opinion has no place in the medical record. All entries must be factual, accurate, complete, current, organized, and confidential.
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Each lung is surrounded by a thin, saclike structure called the:
A) pleura. B) alveoli. C) clavicle. D) pericardium.
The ICD-10-CM Table of Neoplasms is indexed according to anatomic site and contains four cellular classifications, organized in columns: malignant, benign, uncertain behavior, and unspecified nature. Which column classifies the metastasis of cancer?
a. primary malignant b. secondary malignant c. carcinoma in situ d. unspecified nature
Which of the following provides an example of a personal health record application?
A. Electronic health record software B. Computer-assisted coding C. HealthVault interface D. ICD-10-CM encoder
A 33-year-old male complains of generalized weakness and chest discomfort that began following his morning workout at the gym. He is conscious and alert, but restless. Your assessment reveals a BP of 130/64 mm Hg, pulse of 78 beats/min and occasionally irregular, respirations of 16 breaths/min and unlabored, and an SpO2 of 98% on room air. He has prescribed nitroglycerin tablets and states that he took one without relief. Appropriate treatment for this patient includes:
A. oxygen via nonrebreathing mask, one chewable baby aspirin, an IV fluid bolus, and prompt transport. B. oxygen via nasal cannula, up to two more doses of nitroglycerin, saline lock, and transport. C. oxygen via nonrebreathing mask, up to 324 mg aspirin, supine with his legs elevated, and transport. D. oxygen via nasal cannula, up to 324 mg aspirin, saline lock, additional nitroglycerin per medical control, and transport.