Question 1

Objective data are usually recorded

Accepted Answer

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. 
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.

Question 2

Regardless of the orifice, discharge is described by noting

Accepted Answer

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. 
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 3

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

Accepted Answer

A) history of present illness. 
B) review of systems. 
C) physical examination. 
D) patient education. 
E) problem list. 
A) history of present illness. 
B) review of systems. 
C) physical examination. 
D) patient education. 
E) problem list.

Question 4

Differential diagnoses belong in the

Accepted Answer

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

Question 5

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

Accepted Answer

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

Question 6

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

Accepted Answer

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

Question 7

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

Accepted Answer

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. 
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 8

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

Accepted Answer

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. 
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 9

During the course of the interview, you should

Accepted Answer

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. 
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 10

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

Accepted Answer

A) history of present illness. 
B) differential diagnosis. 
C) assessment. 
D) general patient information section. 
E) past medical history. 
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?

Accepted Answer

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 
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

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

Accepted Answer

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

Question 13

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

Accepted Answer

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

Objective data are usually recorded

Regardless of the orifice, discharge is described by noting

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

Differential diagnoses belong in the

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

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

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

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

During the course of the interview, you should

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

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

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

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

The History and Interviewing Process

Cultural Competency

Examination Techniques and Equipment

Vital Signs and Pain Assessment

Mental Status

Growth and Measurement

Nutrition

Skin, Hair, and Nails

Lymphatic System

Head and Neck

Eyes

Ears, Nose, and Throat

Chest and Lungs

Heart

Blood Vessels

Breasts and Axillae

Abdomen

Female Genitalia

Male Genitalia

Anus, Rectum, and Prostate

Musculoskeletal System

Neurologic System

Sports Participation Evaluation

Putting It All Together

Taking the Next Steps: Critical Thinking

Emergency or Life-Threatening Situations

Filters

Exam 26: Recording Information

Objective data are usually recorded

Regardless of the orifice, discharge is described by noting

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

Differential diagnoses belong in the

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

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

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

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

During the course of the interview, you should

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

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

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

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

The History and Interviewing Process

Cultural Competency

Examination Techniques and Equipment

Vital Signs and Pain Assessment

Mental Status

Growth and Measurement

Nutrition

Skin, Hair, and Nails

Lymphatic System

Head and Neck

Eyes

Ears, Nose, and Throat

Chest and Lungs

Heart

Blood Vessels

Breasts and Axillae

Abdomen

Female Genitalia

Male Genitalia

Anus, Rectum, and Prostate

Musculoskeletal System

Neurologic System

Sports Participation Evaluation

Putting It All Together

Taking the Next Steps: Critical Thinking

Emergency or Life-Threatening Situations

Filters