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____ 1. If information is purposefully omitted from the record, you should

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state in the record why the information was omitted.

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____ 2. Which part of the information contained in the patient's record may be used in court?

answer

All information

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____ 3. During the course of the interview, you should

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take brief written notes.

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____ 4. 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

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quote her concerns verbatim.

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____ 5. Subjective and symptomatic data are

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placed in the history sections.

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____ 6. The quality of a symptom, such as pain, is subjective information that should be

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described in the history using a 1-to-10 scale.

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____ 7. Which of the following is an effective adjunct to document location of findings during recording of physical examinations?

answer

Relationship to anatomic landmarks

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____ 8. The position on a clock, topographic notations, and anatomic landmarks

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are methods for recording locations of findings.

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____ 9. Regardless of the orifice, discharge is described by noting

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color and consistency.

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____ 10. Drawing of stick figures is most useful to

answer

compare findings in the extremities.

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____ 11. Which of the following is an example of a problem requiring recording on the patient's problem list?

answer

Findings of unknown origin

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____ 12. A problem may be defined as anything that will require

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evaluation.

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____ 13. Differential diagnoses belong in the

answer

assessment.

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____ 14. When recording assessments during the construction of the problem-oriented medical record, the examiner should

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create an assessment for each problem on the problem list.

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____ 15. Which of the following is not a characteristic of the plan portion of the problem-oriented medical record?

answer

Differential diagnosis

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____ 16. 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)

answer

progress note.

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____ 17. A detailed description of the symptoms related to the chief complaint is presented in the

answer

history of present illness.

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____ 18. The effect of the chief concern on the patient's lifestyle is recorded in which section of the medical record?

answer

History of present illness

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____ 19. The patient's perceived disabilities and functional limitations are recorded in the

answer

past medical history.

question

____ 20. The review of systems is a component of the

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personal and social history.

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____ 21. Allergies to drugs and foods are generally listed in which section of the medical record?

answer

Past medical history

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____ 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.

answer

personal and social

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____ 23. Objective data are usually recorded

answer

by body systems.

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____ 24. Information recorded about an infant differs from that of an adult, mainly because of the infant's

answer

developmental status.

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____ 25. In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?

answer

Present problem

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____ 26. What finding is unique to the documentation of a physical examination of an infant?

answer

Fontanel sizes

question

____ 27. Data relevant to the social history of older adults include information on

answer

family support systems.

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____ 28. A SOAP note is used in which type of recording system?

answer

Problem oriented

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____ 29. The examiner's evaluation of a patient's mental status belongs in the

answer

physical examination.

question

____ 30. When recording physical findings, which data are recorded first for all systems?

answer

Inspection

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____ 31. Regarding another provider's documented work, it

answer

must be attributed to the source if entered.

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____ 32. Which of the following is true regarding the use of "copy and paste, carry forward" (CPCF) in an electronic medical record?

answer

It may be used on medication lists.

question

____ 33. The OLDCHARTS mnemonic is a way of documenting which of the following?

answer

History of present illness

Physical Exam Chpt 26 – Flashcards

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