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Ready-to-use forms are often more expensive to purchase and therefore are used by few facilities.

Incident reports should be filed in the patient record.

Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient’s record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the ____ data recorded in the record.

Incident reports should be filed in the patient record.

Mrs. Bolton is an angry patient who resents her physicians “bossing her around,” refuses to take a portion of the medications that the nurses bring to her pursuant to physician orders, and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton’s behavior in the patient medical record is __________.

Dan Smith has recently moved to a new town. He calls Dr. Jones’ office to make an appointment for an annual history and physical. It is the policy of Dr. Jones’ office to have all new patients request information from their previous health care providers and forward copies to the office prior to their first visit. Dr. Jones reviews Dan’s medical information, which includes treatment for alcohol abuse, depression, and documentation of therapy and treatment. This information would most accurately be referred to as:

Electrocardiogram (EKG) reports include a graphic printout of measurements of the electrical activity of the brain.

Using a SOAP format, which  component would be used to describe test results

Which of the following are factors that influence health record retention periods?

Since the early 1980s, the provision of outpatient services has decreased.