Volume 2 Unit 3 Part 3

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A patient with an illness that is severe, but there is no imminent danger to the patient’s life

Seriously ill (correct)

Very seriously ill

Incapacitating illness or injury

Ill

A patient’s injuries resulted in serious disfigurement

Ill

Seriously ill

Very seriously ill

Incapacitating illness or injury (correct)

A condition so severe that there is imminent danger to the patient’s life.

Incapacitating illness or injury

Very seriously ill (correct)

Seriously ill

Ill

On what form does the health care provider annotate the decision to report a patient in SI, VSI, or III status?

AF Form 3066, Doctor's orders Signup and view all the answers

On what form, does the casualty affairs liaison (CAL) annotate individuals who are notified of a patient’s casualty status?

AF Form 570 Signup and view all the answers

For what purpose is the AF Form 1403, used?

To list patients on casualty status Signup and view all the answers

Who approves an attending physician’s recommendation for the presence of the NOK when it would be beneficial to the patient’s recovery?

MTF commander Signup and view all the answers

Under what circumstances is each military branch allowed to pay for the travel of a patient’s NOK?

For military VSI and SI active duty military patients. Signup and view all the answers

Who is responsible for verifying deaths that occur in an MTF and on Air Force installations?

Physician Signup and view all the answers

Within how many hours after death are remains released to mortuary personnel?

24 Signup and view all the answers

To whom is the personal property of an active duty deceased forwarded?

Appointed summary court officer Signup and view all the answers

To whom are the personal effects of civilians forwarded?

Executor or administration, or, if none is appointed, to the nearest NOK. Signup and view all the answers

Who is responsible for the completion of the death certificate?

Physician Signup and view all the answers

Where is a copy of the death certificate filed?

Inpatient record Signup and view all the answers

Who is the approval authority for a postmortem examination?

Installation commander Signup and view all the answers

What type of duties can you expect to perform while assigned to an inpatient unit?

Health Services Management Duties Signup and view all the answers

Who is responsible for all health record entries regarding diagnoses and procedures?

Health Care Providers Signup and view all the answers

How are corrections to inpatient records made?

Line through incorrect data, do not erase or scratch out. If space permits enter correct data next to erroneous data, if not draw a line through erroneous data, initial and place the correct date next to the entry. Make a note that refers the reader to the correct entry. Go to the location on the inpatient form where the next entry can be made and entered the information using the current date. Signup and view all the answers

What minimum information is required on each form in the inpatient record?

Patient’s name, register number, name of MTF providing treatment, name of MTF maintaining records if different than admitting MTF, family member prefix and SSN. Signup and view all the answers

How are medical records progress notes used?

Used by the physician, dentist, and/or certified nurse midwife to chronologically document the patient’s progress while admitted to the hospital. Signup and view all the answers

What form is used by a physician to transmit written orders for patient care to the nursing staff?

AF Form 3066 Signup and view all the answers

Who authorizes patient absences from the hospital?

Health care provider Signup and view all the answers

What happens when an active duty member leaves the hospital without proper authorization?

They are considered AWOL Signup and view all the answers

What form is used to authorized a patient pass?

AF Form 569 Signup and view all the answers

What patient absence is granted to active duty members and is considered part of the patient's treatment?

Covalescent leave Signup and view all the answers

What is the difference between directed and recommended convalescent leave?

Directed refers to active duty patient’s still admitted to the MTF. The chief of service approves these cases. Recommended refers to active duty patients being discharged. The patient’s unit commander approves these cases. Signup and view all the answers

How does the administrative process of a patient discharge begin?

The unit staff acts upon the order provided by the health care provider Signup and view all the answers

When all required disposition procedures have been completed on the inpatient unit, where is the patient's inpatient record sent?

It is sent to the disposition office or inpatient records section (as determined by local policy). Signup and view all the answers

What form is used, by the patient, to clear the appropriate section within the MTF?

AF Form 577 Signup and view all the answers

What is the final point of clearance listed on the patient clearance record?

The disposition office Signup and view all the answers

What C-Codes commonly referred to?

Pass through codes Signup and view all the answers

What do V-Codes usually identify?

Diagnoses other than disease Signup and view all the answers

What are coding manuals primarily used for?

To classify a wide variety of disease that can cause injury or disease Signup and view all the answers

What does a CPT code describe?

Medical, surgical, and diagnostic services. Signup and view all the answers

What are ICD-9-CM codes?

A 3–5 digit numeric and alphanumeric codes. Signup and view all the answers

When was the final rule for adoption of ICD-10-CM put into use?

January 16, 2009 Signup and view all the answers

Most of the coding in the MTF is done by whom?

Civilians and contractors Signup and view all the answers

What must be done first before coding a patient encounter?

Review the medical documentation to determine the diagnosis and course of care provided/recommended. Signup and view all the answers