Question 1

After a health care provider has gathered information from the patient and performed any necessary investigations, the health care provider then formulates a(n) ________, which could be a diagnosis, identification of the problem, or a differential diagnosis.

Accepted Answer

After a health care provider has gathered information from the patient and performed any necessary investigations (for example: physical exams, laboratory studies, or imaging studies), the health care provider then formulates an assessment, which could be a diagnosis, identification of the problem, or a differential diagnosis.

Question 2

Which of the following is the correct definition for the term chronic?

Accepted Answer

Chronic means that it has been going on for a while now.

Question 3

Which of the following pairs of terms are opposites?

Accepted Answer

Febrile means to have a fever. Afebrile means the patient does not have a fever.

Question 4

The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the ________ part.

Accepted Answer

The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the subjective part of the note.

Question 5

Which of the following health records would NOT include a plan?

Accepted Answer

A pathology report provides a reason for the test, what was on the test, and an assessment.

Question 6

Which of the following health care notes is NOT usually authored in a hospital?

Accepted Answer

An admission summary, a daily hospital/progress note, a discharge summary, and an emergency department note are usually authored in a hospital. A clinic note is most often authored in a clinic.

Question 7

Information such as the patient's physical exam, any laboratory findings, and imaging studies performed during the visit would be contained in which part of the diagnostic process?

Accepted Answer

Information such as the patient's physical exam, any laboratory findings, and imaging studies performed during the visit would be contained in the objective part of the diagnostic process.

Question 8

Which of the following health records describes when and why a patient was admitted to the hospital, documents his/her stay in the hospital, and indicates the type of follow-up the patient will have?

Accepted Answer

A discharge summary describes when and why a patient was admitted to the hospital, documents his/her stay in the hospital, and indicates the type of follow-up the patient will have.

Question 9

The course of action consistent with a health care provider's assessment is known as a(n):

Accepted Answer

The course of action consistent with a health care provider's assessment is known as a plan.

Question 10

A patient complains of itchy skin and has a very noticeable rash. What is an appropriate medical term to describe the rash?

Accepted Answer

Marked means that it really stands out.

Question 11

Which of the following is the correct definition for the term symptom?

Accepted Answer

A symptom is something a patient feels.

Question 12

If a patient's symptoms or disease is becoming more and more severe, evident, etc. each day, it is known as:

Accepted Answer

If a patient's symptoms or disease is becoming more and more severe, evident, etc. each day, it is known as progressive.

Question 13

Which section of the health record is NOT included in the subjective section?

Accepted Answer

The chief complaint as well as the family, past medical, and social histories are all part of the subjective (the patient's personal story of his or her health issues).

Question 14

Which of the following notes is usually authored by a specialist and provides an expert opinion on a more challenging problem?

Accepted Answer

A consult note is usually authored by a specialist who has been consulted to provide an expert opinion on a more challenging problem.

Question 15

A patient concern that just started recently, or is a sudden onset, severe symptom, is called:

Accepted Answer

A patient concern that just started recently, or is a sudden onset, severe symptom, is called acute.

Question 16

The story of the patient's problem is known as:

Accepted Answer

The story of the patient's problem is known as the history of present illness.

Question 17

A patient has unremarkable symptoms. Unremarkable is a medical term used to mean:

Accepted Answer

Unremarkable is another way of saying normal.

Question 18

What is the importance of health records?

Accepted Answer

Health records contain information crucial to patient care, are roadmaps to a patient's health history, and provide a clearer picture of the best route to take in future treatment of the patient.

Question 19

A review of systems is:

Accepted Answer

A review of systems is a description of individual body systems in order to discover any symptoms not directly related to the main problem.

Question 20

Which of the following is FALSE about the SOAP method?

Accepted Answer

Diagnostic work in medicine begins with data collection and concludes with an analysis.

Quiz 2: Introduction to Health Records