Patient Assessment & Documentation Flashcards

A patient presents with dyspnea. In the medical record, this term means:

Answer: Difficulty breathing

Dyspnea is the medical term for shortness of breath or difficulty breathing.

When a physician performs and documents a 'complete ROS,' how many organ systems must be reviewed according to E&M guidelines?

Answer: At least 10 or all applicable systems

A complete ROS requires review of at least 10 organ systems, or documentation that all applicable systems were reviewed.

The physician orders an 'STAT' lab. In medical documentation, STAT means:

Answer: Immediately or without delay

STAT comes from the Latin 'statim,' meaning immediately; it indicates urgent priority for orders.

A scribe documents 'Skin: warm, dry, intact, no rash.' This documentation is part of which exam section?

Answer: Physical Examination

Skin findings based on the provider's direct observation are documented in the Physical Examination section.

What does the term 'afebrile' mean when documented in a patient's chart?

Answer: Without a fever; temperature is normal

Afebrile means the patient has no fever; the prefix 'a-' means without, and 'febrile' means fever.

In HIPAA-compliant documentation, which of the following is considered Protected Health Information (PHI)?

Answer: Patient's name combined with diagnosis

PHI includes any individually identifiable health information such as a patient's name linked to a diagnosis or clinical data.

A physician writes 'Pt tolerated procedure well, d/c home in stable condition.' What does 'd/c' mean in this context?

Answer: Discharged

In this context, 'd/c' means discharged; the patient was sent home after the procedure.