Exam 36: Patient Interview and History

The need for ____ in the medical record makes it essential that medical terminology and precise descriptions are used when charting.

"You seem to be making progress, don't you agree?" is an example of which method of collecting patient data?

Mr. Henderson denies that he is in pain, but you noticed that he grimaces when he stands up and that he moves very slowly and carefully. Which interview skill are you using?

Which method of patient data collection does the statement "So let me see if I understand; The pain only occurs at night." represent?

In response to your questions about social activities, Venira says she and her boyfriend have been dating for two years now, and they are very happy together. Something about her expression makes you think there might be more to the story, however. After a moment, she adds that her boyfriend, a high school football star, has been getting more and more aggressive and recently hit her during an argument. Which of the following might be the cause of this change in his behavior?

Which method for maintaining notes on a patient chart uses a combination of SOMR and POMR?

Signs of substance abuse or ________ can be mistaken for depression.

An increased heart rate, confusion, anxiety, and paranoia are effects of which of the following drugs?

The section of the health history form that contains information about when the problem started and what the patient has done to treat it is the ____.

Which of the following information would be documented under the plan of action?

The question "What would you do if you had chest pain?" represents which of the following methods of patient data collection?

Methods of collecting patient data include mirroring, which includes ____.

Important information about medications (including herbal and OTC) and allergies is found in which section of the health history form?

The patient's name, Social Security number, and birth date are documented in the _______ data section of the health history form.

Stating what you believe the patient is suggesting by his response is a technique known as _______.

The ____ section of the health history form gives the practitioner information about exposure to hazardous substances, sexual practices, and chemical use habits.

The thoughts, feelings, and perception of a patient are _______ data when you document using the SOAP format.

In which year did enforcement of the HIPAA act, dealing with patient's rights, begin with penalties of up to $250,000 in fines and 10 years in jail?

A decreased heart rate and blood pressure, drowsiness, and poor concentration are effects of ____.

Which of the following is an ineffective means of collecting data?