Which of the following is the purpose of an electronic graph, or flow sheet, in a patient's medical record?
To record the patient's demographic information
To record the patient's name, insurance, and next of kin
To record nursing plans and postoperative care
To record vital signs, weight, I&O, and doctor visits
The Correct Answer is D
A. To record the patient's demographic information: Demographic information is recorded in other sections of the medical record, not in a flow sheet.
B. To record the patient's name, insurance, and next of kin: This information is also found in other sections of the medical record, not typically in a flow sheet.
C. To record nursing plans and postoperative care: Nursing plans and postoperative care are documented in different sections, such as care plans or progress notes, not in a flow sheet.
D. To record vital signs, weight, I&O, and doctor visits: Flow sheets or electronic graphs are used to track and visualize ongoing patient data, including vital signs, weight, intake and output (I&O), and doctor visits.
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Correct Answer is B
Explanation
A. NIH (National Institutes of Health): NIH conducts biomedical and public health research but does not regulate laboratory testing.
B. CLIA (Clinical Laboratory Improvement Amendments): This is correct. CLIA regulates laboratory testing and ensures quality standards in the clinical office setting.
C. HHS (Department of Health and Human Services): HHS oversees many health-related programs and agencies, but CLIA specifically regulates laboratory testing.
D. OSHA (Occupational Safety and Health Administration): OSHA regulates workplace safety, not laboratory testing.
Correct Answer is D
Explanation
A. Physicians' Desk Reference: The Physicians' Desk Reference (PDR) provides drug information and is not used for diagnostic coding. It includes details about medications, such as their uses, dosages, and side effects.
B. CPT manual: The CPT (Current Procedural Terminology) manual is used to find codes for procedures and services provided by healthcare professionals, not diagnostic codes.
C. HCPCS: The Healthcare Common Procedure Coding System (HCPCS) is primarily used for coding supplies, equipment, and services not included in the CPT manual. It is not used for diagnostic coding.
D. ICD-10-CM coding manual: The ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) manual is the correct reference for finding diagnostic codes, including those for arteriosclerotic heart disease.