Question 1

Documentation of an extended history of present illness (HPI) includes at least:
A)one HPI element.
B)two HPI elements.
C)three HPI elements.
D)four HPI elements.

Accepted Answer

The answer of Documentation of an extended history of present...

Question 2

Elements of medical decision making include all of the following EXCEPT:
A)number of diagnoses or management options.
B)number of procedures or services provided.
C)amount and/or complexity of data to be reviewed.
D)risk of significant complications, morbidity, and/or mortality.

Accepted Answer

The elements of medical decision making include the number of diagnoses or management options, amount and/or complexity of data to be reviewed, and the risk of significant complications, morbidity, and/or mortality. However, the number of procedures or services provided is not considered as an element of medical decision making.

Question 3

A chart that reports an exam involving at least nine organ systems or body areas would be documentation of a(n):
A)problem-focused exam.
B)expanded problem-focused exam.
C)detailed exam.
D)comprehensive exam.

Accepted Answer

The answer of A chart that reports an exam involving...

Question 4

If a patient states that the pain he or she is experiencing is in the right arm, the element he or she would be describing is the:
A)location.
B)severity.
C)context.
D)quality.

Accepted Answer

The patient is describing the location of the pain in their arm.

Question 5

In documentation of a medical exam, the terms musculoskeletal, respiratory, and gastrointestinal would refer to:
A)body areas.
B)body organs.
C)organ systems.
D)tissue systems.

Accepted Answer

Musculoskeletal, respiratory, and gastrointestinal are all examples of organ systems within the human body. These systems refer to a group of organs that work together to perform a particular function, such as movement or digestion.

Question 6

If a chart note documents that the patient is status post-thyroid resection 10 years ago, this would be an example of the patient's:
A)past history.
B)family history.
C)social history.
D)history of present illness (HPI).

Accepted Answer

The answer of If a chart note documents that the...

Question 7

If a physician examines the system directly related to the problem plus two to nine additional systems, the review of systems (ROS) would be considered:
A)problem pertinent.
B)extended.
C)complete.
D)none of the above.

Accepted Answer

The answer of If a physician examines the system directly...

Question 8

If a patient complains of a dull ache in the left ear over the past 24 hours, he or she would be describing:
A)one history of present illness (HPI) element.
B)two HPI elements.
C)three HPI elements.
D)four HPI elements.

Accepted Answer

The answer of If a patient complains of a dull...

Question 9

If a patient states that the pain he or she is experiencing is burning, the element he or she would be describing is the:
A)associated signs and symptoms.
B)severity.
C)context.
D)quality.

Accepted Answer

The patient is describing the quality of the pain, which in this case is burning. The associated signs and symptoms, severity, and context may provide additional information about the pain, but they are not related to the specific element being described in this case.

Question 10

If a PFSH includes a review of the patient's past, family, and social history, it would be considered:
A)pertinent.
B)complete.
C)comprehensive.
D)detailed.

Accepted Answer

A PFSH (Past, Family, and Social History) that includes a review of the patient's past, family, and social history is considered complete because it encompasses all three components of the PFSH.

Question 11

If a patient states that the present illness started 3 days ago, the element he or she would be describing is the:
A)quality.
B)severity.
C)duration.
D)timing.

Accepted Answer

The element described is "duration," as it refers to how long the illness has been present, in this case, 3 days.

Question 12

If a physician documents that an exam included the measurement of a patient's blood pressure, the system examined would be the:
A)cardiovascular system.
B)respiratory system.
C)neurological system.
D)musculoskeletal system.

Accepted Answer

Blood pressure is a measurement that falls under the cardiovascular system, which includes the heart and blood vessels.

Question 13

An examination that involves one or more organ systems or body areas is called a:
A)general multisystem exam.
B)general organ system exam.
C)single organ system exam.
D)multibody-area exam.

Accepted Answer

A general multisystem exam involves examining multiple organ systems or body areas, while a single organ system exam focuses on a specific organ system. The term "general organ system exam" is not commonly used, and a multibody-area exam is not a recognized medical term.

Question 14

An examination that documents a limited examination of the affected body area or organ system and any other symptomatic or related body areas would be considered a(n):
A)problem-focused exam.
B)expanded problem-focused exam.
C)detailed exam.
D)comprehensive exam.

Accepted Answer

The answer of An examination that documents a limited examination...

Question 15

If a chart note documents that the patient has smoked two packs of cigarettes every day for the past 10 years, it would be an example of the patient's:
A)past history.
B)family history.
C)social history.
D)history of present illness (HPI).

Accepted Answer

The answer of If a chart note documents that the...

Question 16

In documenting a medical examination, all of the following are recognized body areas EXCEPT the:
A)neck.
B)abdomen.
C)back.
D)skin.

Accepted Answer

Skin is not a recognized body area for documenting a medical examination. The recognized body areas are head and neck, chest, abdomen, genitourinary, extremities including joints, neurological, and psychiatric.

Question 17

History of present illness (HPI) types include:
A)brief or extended.
B)brief or detailed.
C)brief or comprehensive.
D)brief or complicated.

Accepted Answer

The answer of History of present illness (HPI) types include:
A)brief...

Question 18

In documenting a medical examination, all of the following are recognized organ systems EXCEPT the:
A)eyes.
B)ears, nose, mouth, and throat.
C)head, including face.
D)skin.

Accepted Answer

The listed organ systems are all recognized in a medical examination.

Question 19

In a patient's chart, a diagnosis:
A)must be explicitly stated.
B)can be stated or implied.
C)must be part of the history of present illness (HPI).
D)must be coded.

Accepted Answer

The answer of In a patient's chart, a diagnosis:
A)must be...

Question 20

All of the following are types of review of systems (ROS) EXCEPT:
A)problem pertinent.
B)extended.
C)comprehensive.
D)complete.

Accepted Answer

The answer of All of the following are types of...

Quiz 10: Auditing

Documentation of an extended history of present illness (HPI) includes at least: A)one HPI element. B)two HPI elements. C)three HPI elements. D)four HPI elements.

Elements of medical decision making include all of the following EXCEPT: A)number of diagnoses or management options. B)number of procedures or services provided. C)amount and/or complexity of data to be reviewed. D)risk of significant complications, morbidity, and/or mortality.

A chart that reports an exam involving at least nine organ systems or body areas would be documentation of a(n): A)problem-focused exam. B)expanded problem-focused exam. C)detailed exam. D)comprehensive exam.

If a patient states that the pain he or she is experiencing is in the right arm, the element he or she would be describing is the: A)location. B)severity. C)context. D)quality.

In documentation of a medical exam, the terms musculoskeletal, respiratory, and gastrointestinal would refer to: A)body areas. B)body organs. C)organ systems. D)tissue systems.

If a chart note documents that the patient is status post-thyroid resection 10 years ago, this would be an example of the patient's: A)past history. B)family history. C)social history. D)history of present illness (HPI).

If a physician examines the system directly related to the problem plus two to nine additional systems, the review of systems (ROS) would be considered: A)problem pertinent. B)extended. C)complete. D)none of the above.

If a patient complains of a dull ache in the left ear over the past 24 hours, he or she would be describing: A)one history of present illness (HPI) element. B)two HPI elements. C)three HPI elements. D)four HPI elements.

If a patient states that the pain he or she is experiencing is burning, the element he or she would be describing is the: A)associated signs and symptoms. B)severity. C)context. D)quality.

If a PFSH includes a review of the patient's past, family, and social history, it would be considered: A)pertinent. B)complete. C)comprehensive. D)detailed.

If a patient states that the present illness started 3 days ago, the element he or she would be describing is the: A)quality. B)severity. C)duration. D)timing.

If a physician documents that an exam included the measurement of a patient's blood pressure, the system examined would be the: A)cardiovascular system. B)respiratory system. C)neurological system. D)musculoskeletal system.

An examination that involves one or more organ systems or body areas is called a: A)general multisystem exam. B)general organ system exam. C)single organ system exam. D)multibody-area exam.

An examination that documents a limited examination of the affected body area or organ system and any other symptomatic or related body areas would be considered a(n): A)problem-focused exam. B)expanded problem-focused exam. C)detailed exam. D)comprehensive exam.

If a chart note documents that the patient has smoked two packs of cigarettes every day for the past 10 years, it would be an example of the patient's: A)past history. B)family history. C)social history. D)history of present illness (HPI).

In documenting a medical examination, all of the following are recognized body areas EXCEPT the: A)neck. B)abdomen. C)back. D)skin.

History of present illness (HPI) types include: A)brief or extended. B)brief or detailed. C)brief or comprehensive. D)brief or complicated.

In documenting a medical examination, all of the following are recognized organ systems EXCEPT the: A)eyes. B)ears, nose, mouth, and throat. C)head, including face. D)skin.

In a patient's chart, a diagnosis: A)must be explicitly stated. B)can be stated or implied. C)must be part of the history of present illness (HPI). D)must be coded.

All of the following are types of review of systems (ROS) EXCEPT: A)problem pertinent. B)extended. C)comprehensive. D)complete.