Question 1

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

Accepted Answer

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. 
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. C

Question 2

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

Accepted Answer

A)  Brief SOAP note 
B)  Comprehensive health history 
C)  Progress note 
D)  Referral note 
A)  Brief SOAP note 
B)  Comprehensive health history 
C)  Progress note 
D)  Referral note A

Question 3

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

Accepted Answer

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

Question 4

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

Accepted Answer

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

Question 5

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

Accepted Answer

A)  attention span. 
B)  developmental status. 
C)  nutritional differences. 
D)  source of information. 
A)  attention span. 
B)  developmental status. 
C)  nutritional differences. 
D)  source of information.

Question 6

Regardless of the origin, discharge is described by noting:

Accepted Answer

A)  a grading scale of 0 to 4. 
B)  color and consistency. 
C)  demographic data and risk factors. 
D)  associated symptoms in alphabetic order. 
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 7

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

Accepted Answer

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 
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 8

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

Accepted Answer

The OLDCARTS mnemonic helps make sure th

Question 9

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

Accepted Answer

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

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

Question 11

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

Accepted Answer

A)  Subjective information only 
B)  Objective information only 
C)  Diagnostic information only 
D)  All information 
A)  Subjective information only 
B)  Objective information only 
C)  Diagnostic information only 
D)  All information

Question 12

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?

Accepted Answer

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. 
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 13

The review of systems is a component of the:

Accepted Answer

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

Question 14

A problem may be defined as anything that will require:

Accepted Answer

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

Question 15

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

Accepted Answer

A)  History of present illness 
B)  Past medical history 
C)  Social history 
D)  Problem list 
A)  History of present illness 
B)  Past medical history 
C)  Social history 
D)  Problem list

Question 16

Subjective and symptomatic data are:

Accepted Answer

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. 
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 17

Which of the following is not a component of the plan portion of the problem-oriented medical record?

Accepted Answer

A)  Diagnostics ordered 
B)  Therapeutics 
C)  Patient education 
D)  Differential diagnosis 
A)  Diagnostics ordered 
B)  Therapeutics 
C)  Patient education 
D)  Differential diagnosis

Question 18

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

Accepted Answer

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

Question 19

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

Question 20

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

Accepted Answer

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

Exam 26: Recording Information

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

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

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

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

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

Regardless of the origin, discharge is described by noting:

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

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

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

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

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

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?

The review of systems is a component of the:

A problem may be defined as anything that will require:

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

Subjective and symptomatic data are:

Which of the following is not a component of the plan portion of the problem-oriented medical record?

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

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

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

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