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 D
Explanation
A. Abandonment: Abandonment involves the discontinuation of care without proper transition, not failure to document.
B. Assault: Assault involves causing apprehension of imminent harm, which is not related to documentation.
C. Battery: Battery refers to physical harm or unauthorized touching, not documentation issues.
D. Negligence: Negligence involves a failure to provide adequate care or follow procedures, such as not documenting adverse reactions properly.
Correct Answer is C
Explanation
A. Consent form: A consent form is a document that gives permission for medical procedures or treatments and is not the same as a superbill.
B. Assignment of benefits: Assignment of benefits is a document that allows the insurance company to pay the provider directly, not a billing form used to summarize charges.
C. Encounter form: A superbill is also known as an encounter form. It details the services provided, diagnosis codes, and charges for a patient’s visit.
D. Advanced beneficiary notice: An advanced beneficiary notice informs patients about services that Medicare may not cover and is not related to billing or charges.