Deck 22: The Patient History and Documentation

Question 1

Which of the following is the most appropriate action for the medical assistant with the uncommunicative patient?

A)Tell the patient that cooperation is mandatory. 
B)Give the patient a sample problem list to review. 
C)Let the physician interview the patient. 
D)Inform the patient of guidelines for expected behavior.

Answer 1

Give the patient a sample problem list to review. 

Question 2

Which of the following is the most appropriate action of the medical assistant when asking a patient about sensitive topics such as alcohol or drug use?

A)Ask sensitive questions at the beginning to get uncomfortable moments over. 
B)Do not make eye contact. 
C)Be judgmental when necessary. 
D)Wait until a good rapport with the patient is established before asking sensitive questions.

Answer 2

Wait until a good rapport with the patient is established before asking sensitive questions.

Question 3

Which of the following components of the review of systems includes joint stiffness, muscle pain, and limitation of movement?

A)Nervous
B)Cardiovascular  
C)Musculoskeletal
D)Gastrointestinal  
E)Respiratory

Answer 3

Musculoskeletal

Question 4

What should the medical assistant do if a patient refuses to answer a question regarding sexual history during the patient interview?

A)Skip the question completely. 
B)Wait until the patient is ready to answer. 
C)Force the issue and ask for answers. 
D)Attempt to return to the question later.

Question 5

Which of the following best describe the major components of the problem-oriented medical record?

A)Problem list, diagnostic and treatment plan, progress notes  
B)Database, problem list, diagnostic and treatment plan  
C)Database, problem list, diagnostic and treatment plan, progress notes  
D)Database, problem list, diagnostic and treatment plan, laboratory reports  
E)Problem list, diagnostic and treatment plan, progress notes, laboratory reports

Question 6

Which of the following best describes the patient's idea of treatment success?

A)Curing the disease  
B)Understanding what caused the illness  
C)Being able to successfully manage the disease  
D)Understanding the physiology of the disease  
E)Getting medications

Question 7

Which of the following is usually contained in the first part of the medical history?

A)Personality
B)Chief complaint  
C)Mental status
D)Social history  
E)Cause of illness

Question 8

Which of the following is the most appropriate action when the medical assistant is taking the medical history?

A)Ask the patient whether there are any questions. 
B)Use medical jargon when possible. 
C)Be firm and inflexible. 
D)Ask intimate questions right away to get them over with.

Question 9

Which of the following statements is true about interviewing?

A)Do not worry about comfort level. 
B)Allow the patient to tell anecdotes. 
C)Do not waste time explaining terms or concepts. 
D)Guide the conversation and keep it on track.

Question 10

Which of the following best describes the physician's overall assessment of major body functions?

A)Review of systems
B)Disease examination  
C)Past medical history
D)Family history  
E)Social history

Question 11

Which of the following is the most appropriate action in order to make a correction when an error has been made in the chart?

A)Cover with Wite-Out®, write over it, and initial and date it. 
B)Erase the error and correct it. 
C)Scribble out the error and write above it. 
D)Draw a single line through the error.Write the correct entry and put initials and date.

Question 12

Which of the following components of the review of systems would include shortness of breath?

A)Nervous
B)Cardiovascular  
C)Musculoskeletal
D)Gastrointestinal  
E)Respiratory

Question 13

Which of the following is the most appropriate action when the patient comes into the office for a singular problem and wants to discuss many problems with the physician?

A)List all the problems under chief complaint. 
B)Remind the patient that the physician's time is limited, but he will try and accommodate if possible. 
C)Tell the patient not to worry because the physician will meet all his needs. 
D)Tell the patient more time is needed and reschedule the appointment.

Question 14

Which of the following best describes the format of a source-oriented medical record?

A)Notes written in SOAP format  
B)Chronological set of notes for each visit  
C)Database, problem list, and examination  
D)All the objective materials gathered about the patient

Question 15

What is the correct order for information placed chronologically in the chart?

A)Primary providers notes, EKGs and x-rays, laboratory reports, pathology reports  
B)Primary providers notes, EKGs and x-rays, hospital notes, consultations, correspondence  
C)Primary providers notes, laboratory reports, pathology reports, hospital notes  
D)Primary providers notes, laboratory reports, pathology reports, consultations  
E)Primary providers notes, hospital notes, laboratory reports, medications

Question 16

Which part of the medical history includes notes about location, quality, and timing?

A)Social history
B)History present illness  
C)Past medical history
D)Family history  
E)Review of symptoms

Question 17

Which of the following components of the review of systems would include change in speech?

A)Neurological
B)Cardiovascular  
C)Musculoskeletal
D)Gastrointestinal  
E)Respiratory

Question 18

Which of the following is NOT a purpose for the patient's medical history?

A)Helps guide the patient's treatment  
B)Allows the provider to recall previous treatment  
C)Allows the patient to help with the diagnosis  
D)Gives a base for statistical analysis

Question 19

Which of the following best describes the first responsibility of the medical assistant when taking the medical history?

A)Wash hands. 
B)Allow freedom of conversation. 
C)Put the patient at ease. 
D)Follow the exact order of the history form. 
E)Obtain personal information first.

Question 20

Which of the following is NOT a common medical records format?

A)Source-oriented
B)Problem-oriented  
C)Patient-oriented
D)None of the above

Question 21

Which of the following is NOT part of the provider's notice of its privacy act according to the HIPAA privacy rule?

A)Describes patient's rights  
B)Explains facilities practices related to PHI  
C)Explains where to file a complaint  
D)Describes various treatments

Question 22

Match the major contents of the medical history with the appropriate descriptions.

medical problems of siblings and parents

A) present illness
B) medical history
C) family history
D) social history

Question 23

Match the charting symbols/abbreviations with the correct meaning.

by mouth

A) po
B) WNL
C) XR
D) Δ

Question 24

You have picked up your equipment and the supplies necessary to obtain a medical history from a new patient.You introduce yourself to the patient after confirming her identity.Then you attempt to put her at ease.What is the next thing you should do?

A)Wash your hands. 
B)Begin to ask questions. 
C)Explain the purpose and importance of information gathering. 
D)Ask about allergies.

Question 25

Which of the following is NOT included on the patient's medical history form?

A)Present health history
B)Body systems review  
C)Insurance history
D)Social history

Question 26

Match the content for each area of the SOAP chart notes with the appropriate description.

assessment

A) weigh subjective and objective findings
B) vital signs
C) symptoms and patient's complaint
D) further tests and treatment

Question 27

Match the content for each area of the SOAP chart notes with the appropriate description.

subjective

A) weigh subjective and objective findings
B) vital signs
C) symptoms and patient's complaint
D) further tests and treatment

Question 28

Match the major contents of the medical history with the appropriate descriptions.

expansion of information that brought the patient to the office

A) present illness
B) medical history
C) family history
D) social history

Question 29

Match the charting symbols/abbreviations with the correct meaning.

within normal limits

A) po
B) WNL
C) XR
D) Δ

Question 30

Which is considered the physician's chief concern?

A)Disease
B)Illness  
C)Treatment
D)Medication

Question 31

Match the content for each area of the SOAP chart notes with the appropriate description.

objective.

A) weigh subjective and objective findings
B) vital signs
C) symptoms and patient's complaint
D) further tests and treatment

Question 32

When you ask the patient questions in the history interview, what is the MOST important consideration?

A)That the patient answer each question  
B)That the patient understand each question  
C)That the patient be allowed to decline to answer  
D)That all questions be repeated

Question 33

Information such as the patient's full name, address, and telephone number would be found on what form?

A)Medical history form
B)Financial information form  
C)Insurance form
D)Demographic data form

Question 34

In the SOAPER charting method, what does the letter "E" represent?

A)Examination
B)Early history  
C)Education
D)Elaboration

Question 35

Match the major contents of the medical history with the appropriate descriptions.

occupation, hobbies, and drug habits

A) present illness
B) medical history
C) family history
D) social history

Question 36

Match the major contents of the medical history with the appropriate descriptions.

all health problems, illnesses, and surgeries

A) present illness
B) medical history
C) family history
D) social history

Question 37

Which is NOT a vulnerable area that HIPAA regulations focus on in regard to medical records and the patient's chart?

A)Paper record storage
B)Fax machines  
C)Photocopies
D)Workstations

Question 38

Which is considered the patient's chief concern?

A)Disease
B)Illness  
C)Treatment
D)Medication

Question 39

Match the content for each area of the SOAP chart notes with the appropriate description.

plan

A) weigh subjective and objective findings
B) vital signs
C) symptoms and patient's complaint
D) further tests and treatment

Question 40

Which of the following is NOT a method used for charting?

A)CHEDDAR
B)SWISS  
C)SOAP
D)SOAPER

Question 41

Match the charting symbols/abbreviations with the correct meaning.

change

A) po
B) WNL
C) XR
D) Δ

Question 42

Match the charting symbols/abbreviations with the correct meaning.

x-ray

A) po
B) WNL
C) XR
D) Δ