Exam 36: Patient Interview and History

Which of the following would you place in the "A" section when using SOAP charting?

The question "Where would you like to begin?" represents which method of data collection?

The history of ________ illness includes detailed information about the chief complaint, including when the problem started and what the patient has done to treat the problem.

Where on the health history form do you document information taken from the administrative sheet?

Many offices use a variation of the _______ note to document routine follow-ups of established patients with ongoing conditions such as hypertension or arthritis.

The ________ is the reason the patient came to visit the practitioner. It should be short and specific and should cover subjective and/or objective data.

Which of the following approaches allows you to determine the patient's knowledge of the situation and whether it is accurate?

When an office uses _______ medical records, the records are accessible at any time and combine SOMR and POMR methods.

The method of collecting patient data that requires more than a yes-or-no answer is asking _________ questions.

Effective ________ means hearing what the patient says, thinking about it, and responding appropriately.

Patient interviews should be conducted in ________ and without interruptions.

Asking the patient "What do you think about this?" allows the patient to evaluate the situation and form an opinion. This is an example of ____.

When you assume an open and relaxed body posture, you are demonstrating which data collection method?

The Joint Commission (TJC) issued a "Do Not Use" list of ________, acronyms, and symbols that should not be used in an effort to reduce medical errors.

Which of the following is charted as subjective data?

Most patient charts are arranged with the entries in reverse _______ order.

The practitioner decides that the patient needs blood and urine tests. The practitioner will document this in the medical record under the _______ of action section in the SOAP format.

The use of alcohol, tobacco, recreational drugs, or other chemical substances is documented in the _______ history.

Which of the following information would you place in the "S" section when using SOAP charting?

Angel dust is also known as ____.