Question 1

Which of the following is true of healthcare institutions regarding documentation?

Accepted Answer

Healthcare institutions must ensure that computer monitors with sensitive patient data are not left unattended to comply with HIPAA regulations, which protect patient privacy.

Question 2

SOAP stands for:

Accepted Answer

SOAP stands for subjective, objective, assessment, and plan, which is a method used in medical documentation to organize information.

Question 3

Which of the following is recorded in documentation as direct patient quotes?

Accepted Answer

The chief complaint is typically recorded as a direct quote from the patient to accurately capture their primary concern in their own words.

Question 4

A patient is examined according to __________, and documentation is recorded according to __________.

Accepted Answer

The examination of a patient is typically conducted by body region, and documentation is recorded according to the system being examined.

Question 5

Which of the following is true of reporting history of present illness?

Accepted Answer

The answer of Which of the following is true of...

Question 6

Which is the preferred order of taking down a patient's subjective information?

Accepted Answer

The preferred order for taking a patient's subjective information is to start with the History of Present Illness (HPI), followed by past medical history, family history, and social history. This sequence helps in understanding the patient's current condition in the context of their overall health background.

Question 7

What is a genogram?

Accepted Answer

A genogram is a visual representation or chart of a patient's family history, often used in medical and psychological contexts to identify patterns or hereditary conditions.

Question 8

In a physical examination, the physician spends the most attention on the patient's musculoskeletal and neurological systems. What can we deduce from this?

Accepted Answer

The physician's focus on the musculoskeletal and neurological systems suggests that the subjective component of the patient's visit, such as symptoms or history, indicated issues in these areas.

Question 9

Which of the following is the last component of gathering objective data?

Accepted Answer

Diagnostic tests are typically the final step in gathering objective data, as they provide specific information that can confirm or rule out conditions suggested by the physical examination and review of systems.

Question 10

Which of the following is true of a problem list that is created during the final assessment?

Accepted Answer

A problem list may include issues that are not true diagnoses, such as symptoms or risk factors, to ensure comprehensive patient management.

Question 11

In the "Plan" section, the text singles out which component of the plan as critical for legal reasons?

Accepted Answer

The answer of In the "Plan" section, the text singles...

Question 12

Which component of the treatment plan is typically reserved for hospitalized patients?

Accepted Answer

The answer of Which component of the treatment plan is...

Question 13

Documentation that just indicates that the healthcare provider found "no problems" is unacceptable because of lack of precision and clarity of what was asked and what was assessed.

Accepted Answer

Documentation should be specific and detailed to ensure clarity about what was evaluated and to provide a clear record for future reference.

Question 14

HIPAA regulations permit healthcare institutions to share a patient's information without their consent, but only to other accredited healthcare institutions and only if strict security measures are in place.

Accepted Answer

HIPAA regulations generally require patient consent to share their information, except in specific circumstances such as treatment, payment, or healthcare operations, and even then, the minimum necessary information should be shared.

Question 15

The format and extent of information gathered are different for each subclassification of the SOAP approach.

Accepted Answer

The answer of The format and extent of information gathered...

Question 16

If the patient reports that 5 years ago she had a "heart attack," it is important for the physician to note this using the patient's own terminology.

Accepted Answer

The physician should document the medical condition using accurate medical terminology, such as "myocardial infarction," while noting the patient's description for context.

Question 17

"Patient holds an M.A. in art history and curates a small museum; occupation calls for standing 6-7 hours a day" is an example of documentation of a patient's social history.

Accepted Answer

This statement provides information about the patient's occupation and educational background, which are aspects of social history.

Question 18

The assessment plan for all patients will contain new diagnoses, differential diagnoses, and a problem list.

Accepted Answer

The answer of The assessment plan for all patients will...

Question 19

Explain what each step of SOAP stands for and why they appear in the particular order they do.

Accepted Answer

The answer of Explain what each step of SOAP stands...

Question 20

What are the five broad categories usually explored in a patient's family history?

Accepted Answer

The answer of What are the five broad categories usually...

Quiz 3: Documentation Strategies