FREE IMAT Critical Thinking Skills Question and Answers
social history
Social history refers to an age-appropriate review of a patient's past and current activities and behaviors that can influence health. This includes information about the patient's daily routine, marital status, occupation, sleeping patterns, smoking habits, alcohol consumption, use of other drugs, and sexual activities. Understanding a patient's social history is crucial for healthcare providers to assess potential risk factors, provide appropriate counseling, and tailor treatment plans to the patient's lifestyle and needs.
inventory of system to document subjective symptoms stated by the pt, provides an opportunity together information that the pt may have seemed unimportant
The term you're describing is likely referring to the Review of Systems (ROS). The ROS is a comprehensive inventory of symptoms organized by body system. It includes subjective symptoms stated by the patient and provides an opportunity for healthcare providers to gather information about the patient's overall health, including symptoms that may not initially seem related to the chief complaint (CC). The ROS helps clinicians gather important information to formulate a differential diagnosis (DDx) and understand the patient's medical history comprehensively.
Against medical advice(AMA)
Against Medical Advice (AMA) refers to a situation where a patient decides to leave a healthcare facility or hospital before the treating physician recommends discharge. When a patient leaves AMA, they sign a release form indicating that they understand the risks and consequences of leaving without following medical advice. This form releases the facility from responsibility for the patient's discharge against medical advice.
review of medical event in the patient's family including disease that maybe hereditary or present a risk to pt
Family history refers to the review of medical events within a patient's family, focusing on diseases or conditions that may have a hereditary component or pose a risk to the patient's health. It involves gathering information about the health status of close family members, such as parents, siblings, and grandparents, to identify any patterns of inherited diseases or conditions that could impact the patient.
documents a patient history of present illness and any pertinent change and physical finding that occurs since a previous in admission if the patient is readmitted within 30 days after discharge for some condition
The term you're describing is likely referring to the Interval History. The Interval History documents a patient's history of present illness and any pertinent changes and physical findings that occur since a previous admission if the patient is readmitted within 30 days after discharge for the same condition. This history helps healthcare providers track the progression of the patient's illness or condition over time and understand any changes that have occurred between hospitalizations.
Primary diagnosis
The term "primary diagnosis" refers to the condition that is chiefly responsible for the patient's admission to the hospital or healthcare facility for care. It is the main reason why the patient sought treatment and is typically the most significant condition requiring medical attention. In healthcare documentation and medical coding, the primary diagnosis is crucial because it determines the course of treatment, procedures performed, and the overall management of the patient's care during the hospitalization or outpatient visit.
doctors orders
The term "doctor's orders" typically refers to the directions provided by a physician to guide the diagnostic and therapeutic care of a patient. This includes specific instructions such as medications to be administered, dosages, frequencies of treatments or procedures, dietary restrictions, and any other necessary actions related to the patient's care. Doctor's orders are essential for ensuring that all healthcare providers involved in the patient's treatment are aware of and follow the prescribed plan of care.
documentation via use of graph of the patient's vital signs
The correct term for documentation via the use of a graph of the patient's vital signs is a "graphic sheet." This type of documentation typically involves a visual representation of the patient's vital signs over a period of time, which allows healthcare providers to track changes and trends in the patient's condition. It is a useful tool for monitoring and assessing a patient's health status during their treatment and recovery.
A documented consultation
This refers to a documented consultation provided by a consulting physician at the request of another physician. The consultation report includes the consulting physician's opinion, findings, and recommendations regarding the patient's condition or treatment.
principal procedure (procedure done for treatment)
In medical coding and billing, the principal procedure is an important component used to accurately capture healthcare services provided during a patient's treatment. It is essential for documenting and justifying the services rendered and plays a role in determining reimbursement and insurance coverage.
pre existing condition that will because of it presence with a specific principal diagnosis cause an increase in pt los by least 1 day in 75% of the case
The term you are referring to is "comorbidity." A comorbidity is a pre-existing medical condition that coexists with a primary diagnosis and can potentially affect the course of treatment or the length of stay in a healthcare setting. According to your description, a comorbidity is considered significant if it leads to an increased length of stay (LOS) by at least one day in 75% of cases with that particular condition. In medical coding and healthcare documentation, comorbidities are important to identify and document accurately because they can impact the complexity of patient care, treatment planning, and resource utilization.