Deck 5: Documentation

Question 1

Allergies to drugs and foods are generally listed in which section of the medical record?

A) History of present illness
B) Past medical history
C) Social history
D) Problem list

Answer 1

Past medical history

Question 2

The patient's perceived disabilities and functional limitations are recorded in the:

A) problem list.
B) general patient information.
C) social history.
D) history of present illness.

Answer 2

history of present illness.

Question 3

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S's loss of appetite, it would be better to:

A) defer or omit her comments.
B) have her husband call you.
C) quote her concerns verbatim.
D) refer her for psychiatric treatment.

Answer 3

quote her concerns verbatim.

Question 4

Which part of the information contained in the patient's record may be used in court?

A) Subjective information only
B) Objective information only
C) Diagnostic information only
D) All information

Question 5

Regardless of the origin, discharge is described by noting:

A) a grading scale of 0 to 4.
B) color and consistency.
C) demographic data and risk factors.
D) associated symptoms in alphabetic order.

Question 6

Which is an effective adjunct to document the location of findings during the recording of the physical examination?

A) Relationship to anatomic landmarks
B) Computer graphics
C) Comparison with other patients of same gender and size
D) Comparison to previous examinations using light pen markings

Question 7

Information recorded about an infant differs from that recorded about an adult, mainly because of the infant's:

A) attention span.
B) developmental status.
C) nutritional differences.
D) source of information.

Question 8

The position on a clock, topographic notations, and anatomic landmarks:

A) are methods for recording locations of findings.
B) are used for noting disease progression.
C) are ways for recording laboratory study results.
D) should not be used in the legal record.

Question 9

The review of systems is a component of the:

A) physical examination.
B) health history.
C) assessment.
D) past medical-surgical history.

Question 10

Data relevant to the social history of older adults includes information on:

A) family support systems.
B) previous healthcare visits.
C) over-the-counter medication intake.
D) date of last cancer screening.

Question 11

Which of the following is not a component of the plan portion of the problem-oriented medical record?

A) Diagnostics ordered
B) Therapeutics
C) Patient education
D) Differential diagnosis

Question 12

Which finding is unique to the documentation of a physical examination of an infant?

A) Fontanel size
B) Liver span
C) Prostate size
D) Thyroid position

Question 13

A SOAP note is used in which type of recording system?

A) Preventive care
B) Problem oriented
C) Systems review
D) Traditional treatment

Question 14

Differential diagnoses belong in the:

A) history.
B) physical examination.
C) assessment.
D) plan.

Question 15

Drawing of stick figures is most useful to:

A) compare findings in extremities.
B) demonstrate radiation of pain.
C) indicate consistency of lymph nodes.
D) indicate mobility of masses.

Question 16

A detailed description of the symptoms related to the chief complaint is presented in the:

A) history of present illness.
B) differential diagnosis.
C) assessment.
D) general patient information section.

Question 17

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record?

A) Chief complaint
B) History of present illness
C) Past medical history
D) Social history

Question 18

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n):

A) progress note.
B) accident report.
C) problem-oriented medical record.
D) triage note.

Question 19

A problem may be defined as anything that will require:

A) evaluation.
B) medication.
C) surgery.
D) treatment.

Question 20

Which is an example of a problem that requires recording on the patient's problem list?

A) Common age variations
B) Expected findings
C) Problems needing further evaluation
D) Minor variations

Question 21

Which format would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

A) Brief SOAP note
B) Comprehensive health history
C) Progress note
D) Referral note

Question 22

George Michaels, a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care?

A) GM is a 22-year-old male here for "allergies."
B) GM came into the clinic complaining of green discharge for the past 72 hours.
C) GM, a 22-year-old male, states that he has allergies and wants them checked.
D) GM is a 22-year-old male here for having "green nasal discharge" for the past 72 hours.

Question 23

The examiner's evaluation of a patient's mental status belongs in the:

A) history of present illness.
B) review of systems.
C) physical examination.
D) patient education.