Free IMAT Critical Thinking Skills Question and Answers — Questions and Answers
Question 1: documentation via use of graph of the patient's vital signs
- ambulance report
- graphic sheet (Correct answer)
- death certificate
- face sheet
Correct answer: graphic sheet
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.
Question 2: A documented consultation
- ambulance report
- consultation report (Correct answer)
- tissue report
- continuum of care
Correct answer: consultation report
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.
Question 3: inventory of system to document subjective symptoms stated by the pt, provides an opportunity together information that the pt may have seemed unimportant
- face sheet
- chief complaint(cc subjective)
- differential diagnosis (DDX)
- review of system (ROS) (Correct answer)
Correct answer: review of system (ROS)
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.
Question 4: 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
- interval history (Correct answer)
- family history
- encounter
- past history
Correct answer: interval history
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.
Question 5: doctors orders
- a record in statement related to the course of patient's illness, cause of treatment and status @ discharge author of the progress note is the physician and written in soap format
- Provision of health services by consulting physician whose opinion or advice is requested by another physician
- reason the patient is seeking treatment and reflects the current most significant, reason for services provided or procedures performed
- Directs the diagnostic and therapeutic patient care I.E. medications and dosages, frequency of dressing change etc (Correct answer)
Correct answer: Directs the diagnostic and therapeutic patient care I.E. medications and dosages, frequency of dressing change etc
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.
Question 6: 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
- principal diagnosis
- tissue report
- complications
- comorbidity (Correct answer)
Correct answer: comorbidity
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.
Question 7: Primary diagnosis
- an out patient record that includes patient registration form ancillary report physician report, nursing documentation etc
- condition established after story to be clearly responsible for occasioning the admission of the pt to the hospital for care.
- reason the patient is seeking treatment and reflects the current most significant, reason for services provided or procedures performed (Correct answer)
- Directs the diagnostic and therapeutic pt care I.E. medications and dosages, frequency of dressing change etc
Correct answer: reason the patient is seeking treatment and reflects the current most significant, reason for services provided or procedures performed
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.
Question 8: Against medical advice(AMA)
- patient description of medical condition stated in the patient own words
- includes patient name and some other pieces of identifying information such as medical record#, DOB, or SS#
- patient who sign themselves out of facility signs a release from responsibility for discharge (Correct answer)
- orders dictated to an authorized facility staff-member because the responsible physician is unable to personally document the order. when verbal order are used they are to be use infrequently and be accepted only by persists authorized by hospital policy and procedures consistent with federal and state laws.
Correct answer: patient who sign themselves out of facility signs a release from responsibility for discharge
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.
Question 9: principal procedure (procedure done for treatment)
- performed for definitive or therapeutic reason rather than diagnostic purpose, or to treat a complication, or that procedure which is must closely related to the principal diagnosis (Correct answer)
- chronological description of patient's present condition from tune of onset to present. HPI should include location quality, severity duration of the condition and associated signs symptoms
- Health information obtained throughout treatment and care of patient. includes health care information obtained about a patient's care and treatment, which is documented on numerous forms in the patient record.
- commonly used in a physician's office to capture charge generated after during an office visit and consists of single page that contain a list of common services provided in the offices
Correct answer: performed for definitive or therapeutic reason rather than diagnostic purpose, or to treat a complication, or that procedure which is must closely related to the principal diagnosis
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.
Question 10: review of medical event in the patient's family including disease that maybe hereditary or present a risk to pt
- interval history
- past history
- family history (Correct answer)
- written order
Correct answer: family history
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.
Question 11: social history
- a record in statement related to the course of patient's illness, cause of treatment and status @ discharge author of the progress note is the physician and written in soap format
- an age appropriate review of past and current activities such as daily routine, marital status occupation, sleeping patterns, smoking use of alcohol and other drugs, sexual activities (Correct answer)
- 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
- form completed by the ambulance emergency medical technicians (emt's) that documents clinical information such as vital signs level of consciousness appearance of the pt etc
Correct answer: an age appropriate review of past and current activities such as daily routine, marital status occupation, sleeping patterns, smoking use of alcohol and other drugs, sexual activities
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.
Free IMAT Critical Thinking Skills Question and Answers
documentation via use of graph of the patient's vital signs