Home health agencies use the OASIS standard to document data that is sent electronically to the state and CMS every ________ days
A) 28 B) 120 C) 60 D) 10 E) 14
C
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Which element identified by a bullet is documented in the words "light head contusion along lateral hairline with no pain upon examination"?
a. Cardiovascular: auscultation of heart with notation of abnormal sounds and murmurs b. Skin: inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers) c. Psychiatric: description of patient's judgment and insight d. Constitutional: general appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
It is important not to over-reach during the draping process
Indicate whether the statement is true or false.
Adjectives such as chronic and acute can be found as:
a. subterms. b. main terms. c. bolded terms. d. italicized terms.
While examining a patient in the ICU, you note that she appears somewhat edematous and the nurse has indicated that the patient's urine output is "minimal." In what section of the medical record would you check to determine the patient's fluid balance (intake vs. output)?
A. physician orders B. consent C. lab results D. nurses' notes and flowsheet