Question

Consider carefully each of these data elements and identify the source document where the information would be abstracted from:

1. Stage of a neoplasm removed during surgery -

2. Whether the patient was transported by an ambulance -

3. The time of death of a patient -

4. If the patient has recently traveled -

5. The estimated amount of blood loss-

6. The surgeon's name performing a surgery -

7. The discharge disposition (where the patient was discharged to) -

8. The admission type (scheduled, emergent versus urgent) -

9. The anticipated payor for this episode of care -

10. The patient's race and gender -

Answer 1

Consider carefully each of these data elements and identify the source document where the information would be abstracted from:

1. Stage of a neoplasm removed during surgery - Surgery removes the tissue around the tumor and tumor during an operation

2. Whether the patient was transported by an ambulance - ADMISSION FILE

3. The time of death of a patient - DISCHARGE TICKET

4. If the patient has recently traveled - ADMISSION FILE ( SOCIAL HISTORY - History Of Recent Travelling ( When , Where , How Many Times ) )

5. The estimated amount of blood loss-

*DOCTORS generally use factors like body weight ,your heart rate, blood pressure, and breathing rate to estimate how much blood may have been lost

*Average blood volume = Patient weight (kg) (Average blood volume in mL/kg)

*GENERAL EXAMINATION - (APPEAREANCE, BODY-BUILD, COLOUR, DECUBITUS, ENVIRONMENT) - VITAL SIGNS - (TEMP, PULSE, B.P, RESPIRATORY RATE, O2 SATURATION )

6. The surgeon's name performing a surgery - PERSONAL HISTORY - PAST HISTORY - MEDICAL HISTORY - DISEASE HISTORY - NAME OF DOCTOR TREATED/ OPERATED

7. The discharge disposition (where the patient was discharged to) - PERSONAL HISTORY - REFRAL HISTORY

8. The admission type (scheduled, emergent versus urgent) - ADMISSION FORM ( TRANSFERRED OR REFERRED FROM )

9. The anticipated payor for this episode of care - PERSONAL HISTORY- NAME OF PAYOR - RELATION

10. The patient's race and gender - PERSONAL HISTORY ( GENDER , RACE )