Question 1

Which of the following is an example of a problem that requires recording on the patient's problem list?

Accepted Answer

A)  Common age variations 
B)  Expected findings 
C)  Problems needing further evaluation 
D)  Minor variations

Question 2

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of this information is part of Ms. G's _____ history.

Accepted Answer

A)  family 
B)  past medical 
C)  personal and social 
D)  present problem

Question 3

The quality of a symptom, such as pain, is subjective information that should be:

Accepted Answer

A)  deferred until the cause is determined. 
B)  described in the history. 
C)  placed in the past medical history section. 
D)  placed in the history with objective data.

Question 4

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S's loss of appetite, it would be better to:

Accepted Answer

A)  defer or omit her comments. 
B)  have her husband call you. 
C)  quote her concerns verbatim. 
D)  refer her for psychiatric treatment.

Question 5

The position on a clock, topographic notations, and anatomic landmarks:

Accepted Answer

A)  are methods for recording locations of findings. 
B)  are used for noting disease progression. 
C)  are ways for recording laboratory study results. 
D)  should not be used in the legal record.

Question 6

During the course of the interview, you should:

Accepted Answer

A)  take no notes of any kind. 
B)  take brief written notes. 
C)  take detailed written notes. 
D)  repeat pertinent comments into a dictation devise.

Question 7

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n):

Accepted Answer

A)  progress note. 
B)  accident report. 
C)  problem-oriented medical record. 
D)  triage note.

Question 8

Differential diagnoses belong in the:

Accepted Answer

A)  history. 
B)  physical examination. 
C)  assessment. 
D)  plan.

Question 9

When recording assessments during the construction of the problem-oriented medical record, the examiner should:

Accepted Answer

A)  combine all data into one assessment. 
B)  create an assessment for each problem on the problem list. 
C)  create an assessment for every abnormal physical finding. 
D)  create an assessment for every symptom presented in the history.

Question 10

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record?

Accepted Answer

A)  Chief complaint 
B)  History of present illness 
C)  Past medical history 
D)  Social history

Question 11

Which finding is unique to the documentation of a physical examination of an infant?

Accepted Answer

A)  Fontanel size 
B)  Liver span 
C)  Prostate size 
D)  Thyroid position

Question 12

Drawing of stick figures is most useful to:

Accepted Answer

A)  compare findings in extremities. 
B)  demonstrate radiation of pain. 
C)  indicate consistency of lymph nodes. 
D)  indicate mobility of masses.

Question 13

Eye examination of the newborn does not routinely include assessment of:

Accepted Answer

A)  the red reflex. 
B)  the corneal reflex. 
C)  object tracking. 
D)  the fundus.

Exam 26: Recording Information