FREE IMAT Critical Thinking Skills Question and Answers

Question 1

documentation via use of graph of the patient's vital signs

Accepted Answer

graphic sheet

Answer

ambulance report

Answer

death certificate

Answer

face sheet

Question 2

A documented consultation

Accepted Answer

consultation report

Answer

ambulance report

Answer

tissue report

Answer

continuum of care

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

Accepted Answer

review of system (ROS)

Answer

face sheet

Answer

chief complaint(cc subjective)

Answer

differential diagnosis (DDX)

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

Accepted Answer

interval history

Answer

family history

Answer

encounter

Answer

past history

Question 5

doctors orders

Accepted Answer

Directs the diagnostic and therapeutic patient care I.E. medications and dosages, frequency of dressing change etc

Answer

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

Answer

Provision of health services by consulting physician whose opinion or advice is requested by another physician

Answer

reason the patient is seeking treatment and reflects the current most significant, reason for services provided or procedures performed

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

Accepted Answer

comorbidity

Answer

principal diagnosis

Answer

tissue report

Answer

complications

Question 7

Primary diagnosis

Accepted Answer

reason the patient is seeking treatment and reflects the current most significant, reason for services provided or procedures performed

Answer

an out patient record that includes patient registration form ancillary report physician report, nursing documentation etc

Answer

condition established after story to be clearly responsible for occasioning the admission of the pt to the hospital for care.

Answer

Directs the diagnostic and therapeutic pt care I.E. medications and dosages, frequency of dressing change etc

Question 8

Against medical advice(AMA)

Accepted Answer

patient who sign themselves out of facility signs a release from responsibility for discharge

Answer

patient description of medical condition stated in the patient own words

Answer

includes patient name and some other pieces of identifying information such as medical record#, DOB, or SS#

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.

Question 9

principal procedure (procedure done for treatment)

Accepted 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

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

Answer

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.

Answer

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

Question 10

review of medical event in the patient's family including disease that maybe hereditary or present a risk to pt

Accepted Answer

family history

Answer

interval history

Answer

past history

Answer

written order