Chapter 1.2, Problem 3E

You are a nurse providing care for a young woman who was involved in a motor vehicle accident. She is brought to your emergency department via ambulance, where your trauma team is in the midst of examining and assessing her. From the initial assessment, her vital signs are measured; she is unconscious with shallow breathing, exhibits several abrasions, is bleeding from a wound in her left thigh, and moans frequently. An intravenous line has been started in her right antecubital vein and normal saline is infusing. (Learning Objective 5) a. Where would you expect to document this information? b. Which topics in the narrative would you expect to be included in proper documentation? c. Which type or model of documentation best suits this type of information? d. What important type of thorough information is missing in the case study? e. Itemize the additional information that should be included. f. What are the benefits of an electronic medical record (EMR) for a patient…

What is typically needed to establish breach of a duty of care? Show answer choices A Causing direct physical harm to a patient (B) Violating a written policy Intending to commit malpractice D Failing to meet the relevant standard of care

TELEPHONE TRIAGE Scenario: You are the MOA in a busy family practice. The following calls come in to your office. For each situation, respond in the most appropriate manner. How would you handle each call?  If it is for your physician, do you put the call through? Do you take a message? Can you handle the call yourself? Provide a brief explanation for each example. "Hello, I would like to make an appointment to see the doctor. I am having some chest pain, and find it a bit hard to breathe.”

a fair-skinned client who is an avid runner is diagnosied with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin reaction, the nurse provides discharge teaching. it is most important for the nurse to emphasizee the need to observe for changes in which characteristic

Which of the following refers to a real time system that allows patients to access their medical records, medication lists, and referrals, in addition to providing the ability to communicate directly with providers and schedule appointments? A Telemedicine B Electronic medical record C Telehealth D Patient portal

Palliative care is only for patients at the end of life. (True/False)

Scenario: You are the MOA in a busy family practice. The following calls come in to your office. For each situation, respond in the most appropriate manner. How would you handle each call?  If it is for your physician, do you put the call through? Do you take a message? Can you handle the call yourself? Provide a brief explanation for each example. “Hi, I would like to make an appointment to see the doctor. I had my X-ray done yesterday, and let me tell you, it was quite an ordeal. First, I had a hard time getting down to the hospital. Then, I got lost… I’m not sure how that can even happen, but then this really nice lady offered…”

When a patient is scheduled for an elective procedure, we can schedule the date, time, and location and prepare the patient for before, during, and after the services they receive. Pre- and post-operative instructions should be written and clearly understood by the patient and their support system. Choose one of the following procedures: Performing incision and drainage of localized infection Aspirating joint fluid Performing hemorrhoid thrombectomy Excising a sebaceous cyst Answer the following questions: (minimum 5 sentences per question) Does the patient need any preparation or education before the procedure? What is informed consent? Does the patient need to sign in for the procedure you chose? If yes, what is the role of the medical assistant when the patient signs an informed consent form? If necessary, how do you clean the skin for this procedure? If necessary, how do you set up the sterile field for this procedure? What are the post-operative instructions for patients who had…

The E/M is used in every specialty including emergency medicine, OB/GYN, ENT, Neuro, and Peds. Pick any specialty and share with the class how coding could be different for each. HINT: Modifier -25, E/M elements, concept of time, established versus new patients.