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 A
Explanation
A. A patient who has a breathing disorder: Fowler’s position (sitting with the head of the bed elevated) can help ease breathing difficulties by allowing better lung expansion.
B. A patient who has severe hypotension: Fowler’s position may exacerbate hypotension. A supine or Trendelenburg position might be more appropriate for severe hypotension.
C. A patient who is having a perineal examination: A lithotomy position is generally used for perineal examinations.
D. A patient who is having a rectal examination: The Sims' position is typically used for rectal examinations.
Correct Answer is A
Explanation
A. Choose procedure codes based on the encounter form. The encounter form, also known as a superbill, lists the procedures and services provided during the visit. The correct procedure codes (CPT codes) should be selected from this form to ensure accurate billing.
B. Upcode for greater reimbursement. Upcoding, or selecting a higher-level code than justified, is illegal and unethical as it constitutes fraud. This should never be done.
C. Refer to ICD-9 for diagnostic codes. ICD-9 codes have been replaced by ICD-10 codes, which are now the standard for diagnostic coding in the United States. Referring to ICD-9 codes would result in incorrect or outdated billing.
D. Enter all data using lowercase letters. Data entry in all lowercase letters is not a standard practice in medical billing and would not affect the accuracy of the codes. Proper case usage is typically recommended for clarity.