Which of the following is a systematic, logical, and consistent recording of a patient's health status in a medical record?

A. operating rules
B. documentation
C. code set
D. encounter


Answer: B

Health Professions

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You are part of your EMS system's QA/QI program. While reading PCRs, you come across one that pertained to a psychiatric emergency in which the patient was restrained. As you review the PCR, which statement would cause you to suspect that the EMS crew needs remedial education?

A) "Each extremity of the patient was restrained with padded leather restraints." B) "The patient was advised repeatedly to adhere to EMS wishes, and was further advised that restraint procedures would occur if he didn't comply." C) "Following extremity restraint, the patient was positioned and secured prone on the cot, with his head turned to the side to allow airway monitoring." D) "The patient failed to comply with repeated instructions of the EMS crew, and became increasingly verbally and physically assaultive. The decision to restrain the patient was agreed upon by the EMS crew, the on-scene PD, and medical direction."

Health Professions

________ needles allow the surgeon to go in and out of a tissue when there is not enough room to maneuver a straight needle.

A. Curved B. Swaged C. Thick D. Thin

Health Professions

Motor skills that require the performer to initiate a specific action on an object according to the object's motion are best categorized as:

A. Closed motor skills B. Discrete motor skills C. Continuous motor skills D. Open motor skills

Health Professions

There are _____ basic steps required for accurate coding.

A. five B. eight C. six D. nine

Health Professions