Deck 2: Introduction to Health Records

Question 1

Which of the following health records describes when and why a patient was admitted to the hospital, documents his/her stay in the hospital, and indicates the type of follow-up the patient will have?

A)Admission summary
B)Clinic note
C)Daily hospital/progress note
D)Discharge summary
E)Emergency department note

Answer 1

Discharge summary

Question 2

The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the:

A)subjective.
B)objective.
C)assessment.
D)plan.
E)none of these.

Answer 2

subjective.

Question 3

A review of systems is:

A)a description of individual body systems in order to discover any symptoms not directly related to the main problem.
B)a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health.
C)any significant illnesses that run in the patient's family.
D)other significant past illnesses, like high blood pressure, asthma, or diabetes.
E)the story of the patient's problem.

Answer 3

a description of individual body systems in order to discover any symptoms not directly related to the main problem.

Question 4

Which of the following pairs of terms are opposites?

A)Acute, abrupt
B)Exacerbation, symptom
C)Febrile, afebrile
D)Genetic, hereditary
E)Lethargic, malaise

Question 5

Which section of the health record is NOT included in the subjective section?

A)Chief complaint
B)Family history
C)Past medical history
D)Review of systems
E)Social history

Question 6

Which of the following health care notes is NOT usually authored in a hospital?

A)Admission summary
B)Clinic note
C)Daily hospital/progress note
D)Discharge summary
E)Emergency department note

Question 7

A patient complains of itchy skin and has a very noticeable rash.What is an appropriate medical term to describe the rash?

A)Alert
B)Marked
C)Objective
D)Oriented
E)Unremarkable

Question 8

Information such as the patient's physical exam, any laboratory findings, and imaging studies performed at the visit would be contained in which part of the diagnostic process?

A)Subjective
B)Objective
C)Assessment
D)Plan
E)None of these

Question 9

After a health care provider has gathered information from the patient and performed any necessary investigations, the health care provider then formulates a(n) ________________, which could be a diagnosis, identification of the problem, or a differential diagnosis.

A)subjective
B)objective
C)assessment
D)plan
E)none of these

Question 10

A patient concern that just started recently, or is a sudden onset, severe symptom, is called:

A)acute.
B)chronic.
C)febrile.
D)lethargic.
E)noncontributory.

Question 11

Which of the following health records would NOT include a plan?

A)Clinic note
B)Consult note
C)Emergency department note
D)Pathology report
E)Prescription

Question 12

What is the importance of health records?

A)They contain information crucial to patient care.
B)They contain roadmaps to a patient's health history.
C)They provide a clearer picture of the best route to take in future treatment of the patient.
D)All of these.
E)None of these.

Question 13

Which of the following notes is usually authored by a specialist and provides an expert opinion on a more challenging problem?

A)Admission summary
B)Clinic note
C)Consult note
D)Daily hospital/progress note
E)Emergency department note

Question 14

If a patient's symptoms or disease is becoming more and more severe, evident, etc.each day, it is known as:

A)abrupt.
B)acute.
C)genetic.
D)malaise.
E)progressive.

Question 15

A patient has unremarkable symptoms.Unremarkable is a medical term used to mean:

A)it stands out.
B)normal.
C)responsive.
D)unresponsive.
E)none of these.

Question 16

Which of the following is FALSE about the SOAP method?

A)Diagnostic work in medicine is very similar to the investigative work of a detective; thus the SOAP method begins with an analysis and ends with collecting data to confirm the diagnosis.
B)Most medical notes share a consistent pattern in their organization and layout that reflects the SOAP thought process.
C)SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
D)SOAP reflects a general thought process used by most medical professionals.
E)The SOAP method is repeated in every health care visit across all disciplines of medicine.

Question 17

Which of the following is the correct definition for the term symptom?

A)All of a sudden
B)It has been going on for a while now.
C)It runs in the family.
D)Not feeling well
E)Something a patient feels

Question 18

Which of the following is the correct definition for the term chronic?

A)All of a sudden
B)It has been going on for a while now.
C)It runs in the family.
D)Not feeling well
E)Something a patient feels

Question 19

The course of action consistent with a health care provider's assessment is known as a(n):

A)subjective.
B)objective.
C)assessment.
D)plan.
E)none of these.

Question 20

The story of the patient's problem is known as:

A)chief complaint.
B)family history.
C)history of present illness.
D)review of history.
E)social history.

Question 21

Prophylaxis refers to:

A)extremely clean, germ-free conditions.
B)observation of a patient.
C)preventative treatment.
D)telling the patient that the problem is not serious or dangerous.
E)treating the symptoms but not actually getting rid of the cause.

Question 22

The term pathogen comes from combining the roots path/o and gen/o.Which are the correct root and term definitions?

A)path/o (development, nourishment) + gen/o (generation, cause) = pathogen (development or nourishment of the cause)
B)path/o (development, nourishment) + gen/o (suffering, disease) = pathogen (development or nourishment of the suffering/disease)
C)path/o (generation, cause) + gen/o (suffering, disease) = pathogen (generation/cause of the suffering/disease)
D)path/o (suffering, disease) + gen/o (development, nourishment) = pathogen (development or nourishment of the suffering/disease)
E)path/o (suffering, disease) + gen/o (generation, cause) = pathogen (generation/cause of the suffering/disease)

Question 23

Which is the correct opposite for the proximal part of the body?

A)Distal
B)Dorsum
C)Ipsilateral
D)Prone
E)Ventral

Question 24

In order to treat the symptoms and make the patient feel better, a medical professional may recommend:

A)discharge.
B)observation.
C)prophylactic medication.
D)reassurance.
E)supportive care.

Question 25

If a patient is prone, he is:

A)lying down on his belly.
B)lying down on his back.
C)lying down on his left side.
D)lying down on his right side.
E)standing.

Question 26

When a medical professional gives a prognosis, he is indicating:

A)the chances for things getting better or worse.
B)the organism that causes the problem.
C)the risk for being sick.
D)the risk for dying.
E)what he thinks the patient has.

Question 27

Which term refers to "before surgery"?

A)L&D
B)OR
C)PACU
D)Post-op
E)Pre-op

Question 28

A CC is usually included on which part of the health care record?

A)Subjective
B)Objective
C)Assessment
D)Plan
E)None of these

Question 29

When a person uses her left hand to reach to the right, she is showing ________________ movement.

A)bilateral
B)contralateral
C)ipsilateral
D)lateral
E)unilateral

Question 30

Which of the following is NOT an abbreviation that refers to a health care facility or department?

A)CTA
B)ECU
C)ER
D)OR
E)PACU

Question 31

A systemic infection by definition:

A)stays in a certain part of the body.
B)infects all or most of the body.
C)is a dangerous problem.
D)is a problem resulting from disease or injury.
E)is the organism that caused the problem.

Question 32

A scan of the body divides the body in slices from left to right.

A)coronal
B)ipsilateral
C)sagittal
D)supine
E)transverse

Question 33

A patient usually has surgery in a(n):

A)ED.
B)ICU.
C)OR.
D)PACU.
E)SICU.

Question 34

Which of the following terms is part of a patient's assessment?

A)Auscultation
B)Family medical history
C)Past surgical history
D)Reassurance
E)Sequelae

Question 35

Which of the following does NOT refer to "the front"?

A)Antral
B)Anterior
C)Dorsal
D)Ventral
E)They all refer to "the front."

Question 36

A PACU is a(n):

A)care unit for cardiac patients.
B)intensive care unit for children.
C)intensive care unit for patients.
D)postanesthesia care unit.
E)recovery room following an operation.

Question 37

During a patient exam, a medical professional may feel parts of the patient's body.This is called:

A)auscultation.
B)diagnosing.
C)palpation.
D)palpitation.
E)percussion.

Question 38

Which of the following is FALSE about the term discharge?

A)It can mean to send home.
B)It is included as part of the "plan" section in a health care note.
C)It literally means to unload.
D)It can mean that the patient has been cured.
E)It refers to a fluid coming out of a part of the body.

Question 39

Which of the following is the best definition for differential diagnosis?

A)A list of conditions the patient may have based on the symptoms exhibited and the results of the exam
B)A problem resulting from a disease or injury
C)Another way of saying assessment
D)The cause
E)What the health care professional thinks the patient has

Question 40

The risk for being sick is known as:

A)malignant.
B)morbidity.
C)mortality.
D)prognosis.
E)remission.

Question 41

The amount of fluids a patient has taken in and produced is abbreviated:

A)BMI.
B)H&P.
C)HPI.
D)I/O.
E)PERRLA.

Question 42

Which of the following abbreviations is NOT part of a patient's history (either medical history or history of the illness)?

A)H&P
B)HPI
C)h/o
D)PMHx
E)CTA

Question 43

The normal blood pressure range is 90/60 to 140/90.A patient's blood pressure has been documented at 120/80.Which of the following abbreviations describes the patient's blood pressure?

A)BP NAD
B)BP NEC
C)BP RRR
D)BP WDWN
E)BP WNL

Question 44

NOS and NEC are:

A)abbreviations used for symptoms and exam findings.
B)catchalls for diagnoses that don't quite fit any specific cause.
C)mean "not otherwise specified" or "not elsewhere classified."
D)all of these.
E)none of these.

Question 45

A discharge summary will often have information regarding the recommended f/u, or ________________ for the patient.

A)future ultrasounds
B)future ultrasonographies
C)future uses
D)following ultrasounds
E)follow up

Question 46

When a patient is examined by a medical professional, which of the following would NOT be part of the physical examination?

A)BP
B)Hx
C)T
D)VS
E)Wt

Question 47

Which of the following pairs of abbreviations are opposites?

A)IM, IV
B)IV, CVL
C)NPO, PR
D)PO, NPO
E)SC, IM

Question 48

A medication prescribed BID is taken:

A)once a day.
B)twice a day.
C)three times a day.
D)before meals.
E)after meals.

Question 49

The prescriber uses which of the following abbreviations if a medication is to be taken before meals?

A)AC
B)PC
C)prn
D)QHS
E)TID

Question 50

Which of the following would NOT describe a patient with a normal physical exam?

A)CTA, RRR
B)CTA, SOB
C)NAD, WDWN
D)PERRLA, A&O
E)WNL

Question 51

PCP refers to the:

A)past care provider.
B)primary care provider.
C)past complaint or problem.
D)present complaint or problem.
E)primary complaint or problem.

Question 52

Interpret the following abbreviations: "The Pt is 5y/o."

A)The patient is 5 years old.
B)The patient is 5 years under observation.
C)The prescription is 5 years old.
D)The prescription is 5 years under observation.
E)None of these.

Question 53

What is the correct definition for the abbreviation RR?

A)Radiology report
B)Rapid rate
C)Recurrent reason
D)Respiratory rate
E)Responsive remission

Question 54

PERRLA means :

A)pathogen is emerging, responsive, and responsive to adversity.
B)patient is equalized, recovering, responsive, and adjusting.
C)physical exam has been reported, responded to, and accepted by insurance.
D)pupils are equal, round, and reactive to light and accommodation.

Question 55

After a car accident, the medical professional asks the patient questions about her name, location, and the date.The patient is able to accurately answer all of the questions.The patient can be classified as :

A)A&O.
B)PERRLA.
C)NAD.
D)ROS.
E)WDWN.

Question 56

Which abbreviation does NOT describe the time of day in which a prescription should be taken?

A)AC
B)PC
C)am
D)QHS
E)TID

Question 57

Which is the correct abbreviation for a medicine administered "as desired"?

A)Ad lib
B)IM
C)NPO
D)PICC
E)PO

Question 58

Which of the following is an accurate breakdown of the abbreviation SC?

A)signa care = signa (label) + care = carefully labeled
B)subcutaneous = sub (above) + cutane/o (skin) = above the skin
C)subcutaneous = sub (beneath) + cutane/o (skin) = beneath the skin
D)subcutaneous = sub (through) + cutane/o(muscle) = through the muscle
E)supportive care (abbreviation comes from regularly used English words)

Question 59

Which of the following is true about the abbreviation CTA?

A)Means "clear to auscultation"
B)Describes normal-sounding lungs
C)Is an abbreviation used by medical professionals after listening (auscultation = "listen")
D)All of these
E)None of these

Question 60

A medicine administered PR is given in the:

A)lungs (respirated).
B)mouth.
C)rectum.
D)skin.
E)vein.

Question 61

The following is an excerpt from a patient's medical record.According to this information, which is NOT true about the patient? T: 98.5; HR: 60; RR: 20; BP: 112/70.
General: Pleasant, responsive.No acute distress.
HEENT: PERRLA.Mucous membranes moist and pink.
Resp: CTA.No wheezes, rales, rhonchi, or crackles.Good air exchange.No increased work of breathing.

A)The patient is afebrile.
B)The patient is alert.
C)The patient's eyes are not reacting to light.
D)The patient's heart rate is 60.
E)The patient's respiratory rate is 20.

Question 62

A patient was given a prescription with the following information: "Sig.5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription?

A)The medication will be taken as needed for ten days.
B)The medication will be taken by mouth once a day for ten days.
C)The medication will be taken by mouth twice a day for ten days.
D)The medication will be taken intravenously for ten days.
E)The medication will be taken subcutaneously for ten days.

Question 63

The following excerpt would most accurately be classified as which kind of health care record? Dear Dr.Childs,
Thank you for referring Mr.Samuels to my office.I saw him on March 3, 2015.Mr.Samuels has a 4-month history of increasing pain in his right distal femur.He first noticed pain after being kicked in the leg at a soccer game and was evaluated in your office 3 weeks later for persistent pain.There was a soft tissue mass in his distal femur that was tender to touch.

A)Consult note
B)Operative report
C)Pathology report
D)Prescription
E)Discharge summary

Question 64

If a patient's infection is classified as malignant, it is:

A)dangerous.
B)getting better.
C)getting worse.
D)hidden.
E)without a known or specific cause.

Question 65

If an infection stays in a certain part of the body, it is:

A)degenerate.
B)localized.
C)malignant.
D)recurrent.
E)systemic.

Question 66

The cause is also called the:

A)diagnosis.
B)etiology.
C)impression.
D)remission.
E)sequelae.

Question 67

Which of the following abbreviations and terms is NOT associated with the assessment in the SOAP method?

A)DDx
B)Idiopathic
C)Mortality
D)Occult
E)WDWN

Question 68

A symptom that a patient has again and that continues to get worse is called:

A)degenerate; malignant.
B)recurrent; degenerate.
C)recurrent; idiopathic.
D)idiopathic; malignant.
E)malignant; recurrent.

Question 69

Which part of the SOAP method most accurately describes the following excerpt from a patient's clinic note? T: 99.0; HR: 60; RR: 20; BP: 112/70.
General: Pleasant, responsive.No acute distress.
HEENT: PERRLA.Mucous membranes moist and pink.
Resp: CTA.No wheezes, rales, rhonchi, or crackles.Good air exchange.No increased work of breathing.

A)Subjective
B)Objective
C)Assessment
D)Plan
E)Prescription

Question 70

Which of the following abbreviations would most likely be found in the "plan" portion of a health record?

A)Dx
B)PERRLA
C)QHS
D)ROS
E)RRR

Question 71

In the following prescription, which line gives the patient instructions? Amoxicillin 400 mg/5ml
Sig)5 ml PO BID x 10days
Dispense 100ml
Refills: None
Brand name medically necessary

A)Amoxicillin 400 mg/5ml
B)Sig.5 ml PO BID x 10days
C)Dispense 100ml
D)Refills: None
E)Brand name medically necessary

Question 72

The following is an excerpt from a consult note. PMHx:
CAD with PTCA in 20xx.Hypertension.Hypertriglyceridemia.
Medications: Beta blocker, nitroglycerin prn, ASA, antilipidemic agent.
Allergies: Penicillin.
FHx: Brother deceased from an MI at 69 years of age.
SHx: Patient does not smoke.He drinks 1-2 beers per week.Denies illicit drug use.He is married with two grown children and three grandchildren.
This information is most accurately classified as:

A)review of systems.
B)past surgical history.
C)patient history.
D)prescription plans.
E)treatment plan.

Question 73

Which is a correct interpretation of the following portion of a physical exam? CV: RRR without murmur, gallops, or rubs.
Resp: CTA bilaterally.

A)Heart has a regular rate and rhythm; lungs are clear on both sides.
B)Heart has a regular rate and rhythm; right lung is clear.
C)Heart rate is normal; lungs are cloudy on both sides.
D)Heart rate is slightly elevated; lungs are clear on both sides.
E)Heart rhythm is normal; left lung is cloudy.

Question 74

The following is an excerpt from a patient's discharge summary.Which of the following is NOT true about this excerpt? HPI
Miss Susan Nesbit is a 12-year-old female who first visited her primary care provider for dysuria.A UA was ordered, but the patient could not urinate in the office.She took the UA cup home but did not return with the sample.The next day, Susan's dysuria worsened, and she developed a fever of 102.3^o F, as well as vomiting and hematuria, so she returned to the clinic.A urinalysis performed in the office revealed significant pyuria, hematuria, and albuminuria.Since Susan was not able to keep any fluids down, her primary care provider sent her to the emergency department for evaluation for admission.

A)Her PCP sent her to the ED for evaluation and admission.
B)It contains the history of the present illness.
C)The patient is 12 y/o.
D)The patient returned to the clinic when her dysuria worsened and she became febrile.
E)The patient went to the ED before seeing her PCP.

Question 75

If a patient's infection is classified as occult, it is:

A)dangerous.
B)getting better.
C)getting worse.
D)hidden.
E)without a known or specific cause.

Question 76

Which of the abbreviations would be a correct reflection of the following Emergency Department note? Physical Exam
Vital Signs: Temperature: 102.3; Heart Rate: 90; Respiratory Rate: 20;BP: 112/84.
General: Well-developed and nourished, in mild discomfort.Alert andoriented x 3.

A)Vital Signs: T: 90; HR: 90; RRR; BP: 112/84
General: WDWN, in mild discomfort.A&Ox3
B)Vital Signs: T: 102.3; HR: 90; RR: 20; BP: 112/84
General: WDWN, in mild discomfort.A&Ox3
C)Vital Signs: T: 102.3; HR: 90; RR: 20; BP: 112/84
General: WW, in mild discomfort.A&Ox3
D)Vital Signs: T: 102.3; HtR: 90; RR: 20; BldPres: 112/84
E)Vital Signs: Temp: 102.3; HtR: 90; RR: 20; BP: 112/84

Question 77

Which of the following is an accurate breakdown of the abbreviation IM?

A)instrumental = the essential portions of a patient's health record
B)intermedical = inter (between) + medic/o (medicine) + al (pertaining to) = information shared between medical professionals
C)intramicrobial = intra (in, inside) + micro (small) + bial (pertaining to) = pertaining to the small microorganisms for which a prescription is dedicated
D)intramuscular = intra (in, inside) + muscul/o (muscle) + ar (pertaining to) = inside a muscle
E)None of these

Question 78

From which portion of a consult note is the following excerpt? Reason for Consult: urinary retention
HPI: Mr.Johnson is a 57-year-old male with a 2-month history of difficulty voiding.He reports urgency and frequency.He has had increasing problems with a weakurinary stream.The symptoms have progressed to include mild abdominal discomfortand erectile dysfunction.He denies any incontinence, hematuria, balanorrhea, orchiodynia, or trauma.He has not tried any medicines at this point.
PMHx: Hypercholesterolemia-currently controlled with diet.Positive history of gonococcalurethritis 3 years previously.No history of urolithiasis.

A)Subjective
B)Objective
C)Assessment
D)Plan
E)Prescription

Question 79

According to the following discharge summary, which is true about this patient? HPI
Mrs)Roxana Collach presented to the ED with a 2-day history of increasing epigastric pain.She described the pain as constant and dull with radiation to her back.She also had progressive anorexia.She denied nausea, emesis, or diarrhea.She was febrile in the ED and had marked epigastric tenderness on exam with guarding.Her abdomen was slightly distended and she was mildly jaundiced.Her elevated amylase and lipase confirmed the suspicion of acute pancreatitis.She was admitted for pain control and IVF.

A)Her anorexia was getting better.
B)Her anorexia was getting better.Her anorexia was getting better.
C)She did not have any epigastric tenderness.
D)She was diagnosed with pancreatitis.
E)She was not given intravenous fluids.

Question 80

According to the following discharge summary, which of the following is NOT true about this patient? Discharge Physical Examination
Temp: 98.6; RR: 24; HR: 86; BP: 100/64.
Gen: WDWN.Alert.
CV: RRR.
Resp: CTA.
GI: Abdomen soft, nondistended, mild tenderness to palpation over the surgical incisions.Three small horizontal surgical wounds in her abdomen.Wounds clean, dry, and intact.
Activity
No restrictions.

A)The patient does not have a fever.
B)The patient experiences mild tenderness when her surgical incisions are touched.
C)The patient's heart is beating rapidly.
D)The patient looks well-developed and well-nourished.
E)The patient's lungs sound clear.