Deck 4: Content of the Health Recordthe Past Medical, Surgical, Family, and Social Histories

Question 1

You are designing a registration form. The patient's employer is a data field. What related data might you also collect regarding the patient's employer, and why?

Answer 1

Key pieces of data are name of employer, address of employer, phone number, position within the company, and how long the patient has been with the company. It is important to collect detailed information about the employer so that the office has a secondary phone number to reach the patient, if necessary, for collections purposes, should there be issues with his or her account. Also, the patient's position and how long the patient has been with a company may have a bearing on his or her health status (for example, a person who lays carpet for a living may exhibit chronic knee pain). This data is collected for insurance purposes and as part of the reimbursement process; it is a way of locating the patient, should he or she stop paying an outstanding balance on a bill.

Question 2

The "box" where data is entered on an electronic medical record, for instance Patient's Last Name, is commonly called a field. What is the other name for field?

Answer 2

label

Question 3

Which of the following is not a vital sign?

A) heart rate
B) blood pressure
C) temperature
D) complete blood count

Answer 3

complete blood count

Question 4

List and explain three elements that may be included in a patient's social history.

Question 5

Emily Haver documented on her past history form that she had an arthroscopy of the right knee in 2005. On her next visit, the care provider was reviewing her past surgical history and mentioned that she had right knee arthroscopy. The patient realized she had written the wrong side and confirmed that it was her left knee which underwent arthroscopy. What action will the care provider take in this case?

A) Nothing, leave the documentation as is, since that is what the patient initially stated.
B) Place a paper note in the patient's folder noting there is an error in the patient's electronic record.
C) Amend the record to show the corrected information, according to office policy.
D) Have the office manager take care of it.

Question 6

What are the three pieces of data that should be on every page of a paper record, even on the front and the back of a two-sided document, in order to ensure each form is on the correct patient's record?

Question 7

The information collected on a form (paper or electronic) should be relevant to the purpose of the form. Explain that statement and give an example (other than the one used in the text).

Question 8

What is the patient's marital status?

A) single
B) married
C) divorced
D) widowed

Question 9

You have just entered data into an online form. The box in which you entered the information is known as a

A) locator.
B) field.
C) menu item.
D) space.

Question 10

What is the reason the patient made an appointment for July 5, 2011?

A) COPD
B) hypertension
C) lumbago
D) confusion

Question 11

Of the following, which is not part of the patient's past medical or surgical history?

A) allergies
B) current medications
C) marital status
D) dates of previous surgery

Question 12

Explain how EHR software, including Prime Suite, ensures that the correction of or amendment to an electronic record is made without jeopardizing the integrity of the record.

Question 13

Natalie Burns has just arrived for her 1:00 p.m. appointment with Dr. Earl. She informs the healthcare professional that she is there for a follow-up of her hypertension. This is known as Natalie's

A) chief complaint.
B) history of present illness.
C) diagnosis.
D) past medical history.

Question 14

Sarah Armel has been a smoker for 15 years. She smokes one pack per day. This is noted in which section of Sarah's history?

Question 15

Which of the following typically would not be collected as part of the past surgical history?

A) name of operation
B) name of surgeon
C) approximate date of the operation
D) name of the anesthesiologist

Question 16

Craig James is in the office of Dr. Hammer for his annual physical. Dr. Hammer asks Craig a series of questions such as "do you have frequent headaches," "do you have frequency of urination," and "do you have difficulty sleeping." These questions are part of the

A) physical exam.
B) patient medical history.
C) review of systems.
D) social history.

Question 17

Every form should include the _______________ so that the form's use is obvious.

A) patient's name
B) provider's name
C) form name
D) patient's chart number

Question 18

Explain why electronic forms may not replace paper forms entirely.

Question 19

Explain why collecting a patient's family history is important to a care provider. Give an example (other than the one given in the text).

Question 20

What information within the history may be a predictor of the patient's future health?

Question 21

The patient's medication list includes _____________________.

Question 22

What is meant by the statement "Paper forms are often source documents used to enter data into an EMR"?

Question 23

Explain why each page of a multipage form should include the patient's name, date of birth (DOB), and the medical record number.

Question 24

The patient's past medical history includes _______________________.

Question 25

Explain why cloning is a practice that should be used carefully in the medical field.

Question 26

The patient's past surgical history includes ____________________________.

Question 27

What should a medical practice or hospital have that should result in proper handling of inconsistent or unclear information within a health record?

Question 28

In the progress note above, the patient's chief complaint is _______________________.