Health records are classified as primary or secondary records. Give an example of each type
What will be an ideal response?
Primary records are those that are gathered directly from the patient and his or her provider. Examples include patient history, SOAP note, doctor's notes, admission or discharge reports, nursing notes, orders, lab results, radiology reports, patient history, problem list, medications list, as well as data obtained from devices.
Secondary records are those that are created later when analyzing, summarizing, or abstracting from the primary records. Examples include the master patient index, insurance claims, patient bills, and aggregate data used for research and statistical reports (ALOS was given as an example).
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A) air B) rubber C) wood D) water
What is an Apgar assessment?
A. An abnormal opening that is surgically created to allow the release of feces from the body via an opening other than the anus B. Five different assessments performed at the time of birth that determine the patient's blood flow, heart rate, respiratory function, and neurologic function C. The manual application of pressure to the chest for the purpose of restoring heart function; most often associated with cardiopulmonary resuscitation D. The manual establishment of the functions of heart and lungs after a sudden cessation of normal cardiac or respiratory function