Deck 26: Recording Information

Question 1

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

Answer 1

All information

Question 2

The review of systems is a component of the:

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

Answer 2

health history.

Question 3

A problem may be defined as anything that will require:

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

Answer 3

evaluation.

Question 4

Which of the following 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 5

Differential diagnoses belong in the:

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

Question 6

If information is purposely omitted from the record, you should:

A) erase the notes that are not pertinent.
B) accept that sometimes data are omitted.
C) state in the record why the information was omitted.
D) use correction fluid to cover the information.

Question 7

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 8

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.

Question 9

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 10

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

A) problem list.
B) general patient information.
C) social history.
D) past medical history.

Question 11

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.
C) placed in the past medical history section.
D) placed in the history with objective data.

Question 12

Subjective and symptomatic data are:

A) documented with the physical examination findings.
B) not mentioned in the legal chart.
C) placed in the history section.
D) recorded with the examination technique.

Question 13

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

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

Question 14

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 15

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.

Question 16

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 dictation devise.

Question 17

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 18

Which of the following 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 19

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 20

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 21

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

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

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

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 this information is part of Ms. G's _____ history.

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

Question 24

Eye examination of the newborn does not routinely include assessment of:

A) the red reflex.
B) the corneal reflex.
C) object tracking.
D) the fundus.

Question 25

When using the mnemonic OLDCARTS, the A stands for ______________________.

Question 26

Which of the following formats 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 27

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 28

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

A) Inspection
B) Percussion
C) Palpation
D) Auscultation

Question 29

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

A) Preventive care
B) Problemoriented
C) Systems review
D) Traditional treatment

Question 30

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.

Question 31

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

Question 32

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

A) Family
B) Past medical
C) Personal and social
D) Present problem

Question 33

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