EHR – Ch #4 – Flashcards

You have just entered data into an online form. The box in which you entered the information is known as a/an: a) locator b) field c) menu item d) space

Every form should include the _______________ so that the form's use is obvious. a) patient's name b) provider's name c) form name d) patient's chart number

Of the following, which is not part of the patient's past medical or surgical history? a) allergies b) current medications c) marital status d) dates of previous surgery

Which of the following typically would not be collected as part of the past surgical history? a) name of operation b) name of surgeon c) approximate date of the operation d) name of the anesthesiologist

Natalie Burns has just arrived for her 1:00 p.m. appointment with Dr. Earl. She informs the healthcare professional that she is there for a follow-up of her hypertension. This is known as Natalie's: a) chief complaint b) history of present illness c) diagnosis d) past medical history

Craig James is in the office of Dr. Hammer for his annual physical. Dr. Hammer asks Craig a series of questions such as "do you have frequent headaches," "do you have frequency of urination," and "do you have difficulty sleeping." These questions are part of the: a) physical exam b) patient medical history c) review of systems d) social history

What is the reason the patient made an appointment for July 5, 2011? a) COPD b) hypertension c) lumbago d) confusion (Insert photo)

What is the patient's marital status? Insert picture

Emily Haver documented on her past history form that she had an arthroscopy of the right knee in 2005. On her next visit, the care provider was reviewing her past surgical history and mentioned that she had had right knee arthroscopy. The patient realized she had written the wrong side, and confirmed that it was her left knee which underwent arthroscopy. What action will the care provider take in this case? a) Nothing, leave the documentation as is, since that is what the patient initially stated. b) Place a paper note in the patient's folder noting there is an error in the patient's electronic record. c) Amend the record to show the corrected information, according to office policy. d) Have the office manager take care of it.

Which of the following is not a vital sign? a) heart rate b) blood pressure c) body mass index d) complete blood count