Deck 3: Documentation Strategies

Question 1

Which of the following is true of healthcare institutions regarding documentation?

A) To comply with HIPAA regulations, institutions must ensure that computer monitors with sensitive patient data are not left unattended.
B) All institutions must follow a standard policy for posting abbreviations in documentation drawn from the AMA.
C) Institutions consider drawings a fairly inaccurate way to represent a patient's systems or picture of the patient's condition.
D) As of 2003, faxes may no longer be used to share patient medical information between institutions.

Answer 1

A

Question 2

SOAP stands for:

A) standard operating and admitting procedures.
B) sanitation, observation, auscultation, palpation.
C) surgeons, officials, administrators, patients.
D) subjective, objective, assessment, plan,

Answer 2

D

Question 3

Which of the following is recorded in documentation as direct patient quotes?

A) The chief complaint and follow-up responses
B) The chief complaint only
C) Nothing; everything is written in precise medical terminology
D) The objective information

Answer 3

B

Question 4

A patient is examined according to __________, and documentation is recorded according to __________.

A) PQRST, CLIENT OUTCOMES
B) body region, system
C) subjective data, objective data
D) the institution's system, the physician's system

Question 5

Which of the following is true of reporting history of present illness?

A) If a patient describes having pain in the arm and numbness in the fingertips, the physician should examine these as a single unit.
B) The opening sentence should contain the results from pertinent test results and test dates.
C) All recent pertinent diagnostic tests and the outcomes of recent pertinent interventions should be summarized and included in the HPI.
D) Medical tests that are unrelated to their current complaint should be included in the HPI.

Question 6

Which is the preferred order of taking down a patient's subjective information?

A) Family history, physical exam, diagnostic tests, assessment
B) SOAP
C) HPI, past medical history, family history, social history
D) HPI, family history, physical exam, assessment

Question 7

What is a genogram?

A) A genetic test performed in a doctor's office
B) A visual representation or chart of a patient's family history
C) A biometric monitor worn during a physical exam
D) A computer report correlating information from the patient's history, exam, and diagnostic tests

Question 8

In a physical examination, the physician spends the most attention on the patient's musculoskeletal and neurological systems. What can we deduce from this?

A) The same systems were likely not explored in the review of systems.
B) This is a comprehensive examination.
C) Documentation from the subjective component of the patient's visit has pointed the physician to these systems.
D) The diagnosis will be firmly established after assessment of both systems.

Question 9

Which of the following is the last component of gathering objective data?

A) Review of systems
B) Physical examination
C) Assessment
D) Diagnostic tests

Question 10

Which of the following is true of a problem list that is created during the final assessment?

A) It outlines the educational needs of the patient.
B) It includes additional findings that are directly related to the history of present illness.
C) It may include other issues that are not true diagnoses.
D) Items on the problem list typically cannot be treated.

Question 11

In the "Plan" section, the text singles out which component of the plan as critical for legal reasons?

A) Education
B) Nonpharmacological interventions
C) "Rule outs"
D) Follow-up

Question 12

Which component of the treatment plan is typically reserved for hospitalized patients?

A) Pharmacological interventions
B) Referrals
C) Nonpharmacological interventions
D) Follow-ups

Question 13

Documentation that just indicates that the healthcare provider found "no problems" is unacceptable because of lack of precision and clarity of what was asked and what was assessed.

Question 14

HIPAA regulations permit healthcare institutions to share a patient's information without their consent, but only to other accredited healthcare institutions and only if strict security measures are in place.

Question 15

The format and extent of information gathered are different for each subclassification of the SOAP approach.

Question 16

If the patient reports that 5 years ago she had a "heart attack," it is important for the physician to note this using the patient's own terminology.

Question 17

"Patient holds an M.A. in art history and curates a small museum; occupation calls for standing 6-7 hours a day" is an example of documentation of a patient's social history.

Question 18

The assessment plan for all patients will contain new diagnoses, differential diagnoses, and a problem list.

Question 19

Explain what each step of SOAP stands for and why they appear in the particular order they do.

Question 20

What are the five broad categories usually explored in a patient's family history?