Deck 26: Recording Information

Question 1

Drawing of stick figures is most useful to

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

Answer 1

compare findings in the extremities.

Question 2

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)are usually misinterpreted.
E)should not be used in the legal record.

Answer 2

are methods for recording locations of findings.

Question 3

Subjective and symptomatic data are

A)documented in your assessment.
B)not mentioned in the legal chart.
C)placed in the history sections.
D)recorded with the examination technique.
E)documented with the findings.

Answer 3

placed in the history sections.

Question 4

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

A)A plan is developed for each problem.
B)Therapeutics
C)Patient education
D)Differential diagnosis
E)Diagnostics ordered

Question 5

If information is purposefully omitted from the record, you should

A)erase the notes that are not pertinent.
B)never explain the emission.
C)state in the record why the information was omitted.
D)use correction fluid to omit the information.
E)know that only helpful data are recorded.

Question 6

The effect of the chief concern 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)General patient information
E)Social history

Question 7

Regardless of the orifice, discharge is described by noting

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

Question 8

The review of systems is a component of the

A)physical examination.
B)health history.
C)assessment.
D)past medical and surgical history.
E)personal and social history.

Question 9

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)incident report.
C)problem-oriented medical record.
D)triage note.
E)new problem list.

Question 10

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.
E)past medical history.

Question 11

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

A)Relationship to anatomic landmarks
B)Computer graphics
C)Comparing with other patients of same gender and size
D)Comparing to previous examinations using light pen markings
E)Scale drawings specific to the patient

Question 12

When recording assessments during the construction of the problem-oriented medical record, the examiner should

A)combine all data into one assessment.
B)create an assessment for each problem on the problem list.
C)create an assessment for every abnormal physical finding.
D)create an assessment for every symptom presented in the history.
E)create an assessment for each abnormal laboratory finding.

Question 13

Which of the following is an example of a problem requiring recording on the patient's problem list?

A)Common age variations
B)Expected findings
C)Findings of unknown origin
D)Minor variations
E)Only findings that have a clear etiology

Question 14

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

A)Subjective information
B)Objective information
C)Diagnostic information
D)Consultations
E)All information

Question 15

The quality of a symptom, such as pain, is subjective information that should be

A)deferred until the cause is determined.
B)described in the history using a 1-to-10 scale.
C)placed in the past medical history section.
D)placed in the history with objective data.
E)interpreted in light of your physical findings.

Question 16

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

A)problem list.
B)general patient information.
C)social history.
D)review of systems.
E)past medical history.

Question 17

During the course of the interview, you should

A)take no notes of any kind.
B)take brief written notes.
C)take detailed written notes.
D)repeat pertinent comments into a Dictaphone.
E)interrupt the interview to formulate your thoughts.

Question 18

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.
E)record your interpretations.

Question 19

A problem may be defined as anything that will require

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

Question 20

Differential diagnoses belong in the

A)history.
B)physical examination.
C)assessment.
D)plan.
E)laboratory data.

Question 21

Data relevant to the social history of older adults include information on

A)family support systems.
B)extra time to assume positions.
C)over-the-counter medication intake.
D)date of last cancer screening.
E)previous health care visits.

Question 22

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G's _____ history.

A)identifying information
B)past medical
C)personal and social
D)present problem
E)family

Question 23

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

A)attention span.
B)developmental status.
C)nutritional differences.
D)source of information.
E)limited past medical history.

Question 24

Regarding another provider's documented work, it

A)is not relevant in a legal proceeding.
B)will not affect clinical decisions.
C)may be copied verbatim into your documentation.
D)must be attributed to the source if entered.
E)does not affect patient care.

Question 25

Which of the following is true regarding the use of "copy and paste, carry forward" (CPCF) in an electronic medical record?

A)It is never acceptable.
B)It can decrease efficiency.
C)It increases the chance of information drop-off.
D)It may be used on medication lists.
E)It increases the chance of typing errors.

Question 26

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

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

Question 27

The OLDCHARTS mnemonic is a way of documenting which of the following?

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

Question 28

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.
E)problem list.

Question 29

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

A)General patient information
B)Past medical history
C)Social history
D)Problem list
E)History of present illness

Question 30

In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?

A)Family
B)General patient information
C)Personal and social
D)Present problem
E)Past medical

Question 31

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

A)Fontanel sizes
B)Liver span
C)Prostate size
D)Thyroid position
E)Visual acuity

Question 32

When recording physical findings, which data are recorded first for all systems?

A)Review of systems
B)Percussion
C)Palpation
D)Auscultation
E)Inspection

Question 33

Objective data are usually recorded

A)by body systems.
B)in the history.
C)subsequent to the assessment and plan.
D)before the health history.
E)in the problem list.