Question 1

Which of the following is FALSE about the term discharge?

Accepted Answer

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 2

A medication prescribed BID is taken:

Accepted Answer

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

Question 3

According to the following discharge summary, Ms. Cloud began complaining of ophthalmalgia. Hospital Course
On postop day 2, Ms. Cloud began complaining of increasing right ophthalmalgia. She was noted to be febrile to 102.2. Exam revealed conjunctival infection and edema. She was presumed to have postoperative endophthalmitis. Vitrectomy was performed under sterile conditions, and samples were sent to lab for culture. She was given intravitreal antibiotics. Over the next couple of days, her fever curve trended down and her WBC count improved. Cultures came back positive for S. epidermidis. Infectious disease was consulted; they recommended two weeks of IV therapy. A PICC line was placed and she was discharged with care instructions.
Which is the correct definition of the suffix -algia?

Accepted Answer

A)  Cause 
B)  Hernia 
C)  Medical science 
D)  Pain 
E)  Specialist

Question 4

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

Accepted Answer

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

Question 5

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

Accepted Answer

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

Question 6

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

Accepted Answer

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

Question 7

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

Accepted Answer

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

Question 8

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

Accepted Answer

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

Question 9

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.

Accepted Answer

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

Question 10

The inferior vena cava is also known as the posterior vena cava. From the terms inferior and posterior, one can say that this vein is ________ the heart on the ________ side.

Accepted Answer

A)  above, back 
B)  above, front 
C)  below, back 
D)  below, front

Question 11

Which of the following is true about the abbreviation CTA?

Accepted Answer

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 12

Which term refers to "before surgery"?

Accepted Answer

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

Question 13

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

Accepted Answer

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

Question 14

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

Accepted Answer

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

Question 15

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

Accepted Answer

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 16

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, 2017. 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.

Accepted Answer

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

Question 17

If a person's head were divided on the coronal plane, which of the following is TRUE?

Accepted Answer

A)  The division would be from front to back, and therefore both eyes could be seen on the same plane. 
B)  The division would be from front to back, and therefore only one eye would be seen at a time. 
C)  The division would be from left to right, and therefore both eyes could be seen on the same plane. 
D)  The division would be from left to right, and therefore only one eye would be seen at a time.

Question 18

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.

Accepted Answer

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

Question 19

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

Accepted Answer

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

Question 20

The following excerpt most likely comes from what time of health record? ED Course:
Elizabeth arrived in the ED lethargic but responsive. Given her history and vomiting, we were concerned about diabetic ketoacidosis. The patient's finger stick blood sugar test result of 320 confirmed hyperglycemia, and a urinalysis revealed both glucosuria and ketonuria. An IV was started and labs were sent for review. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for patient transfer to the PICU.
Disposition: Transfer to PICU.

Accepted Answer

A)  Clinic note 
B)  Emergency department note 
C)  Operative report 
D)  Pathology report 
E)  Radiology report

Exam 2: Introduction to Health Records

Which of the following is FALSE about the term discharge?

A medication prescribed BID is taken:

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

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

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

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

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

The inferior vena cava is also known as the posterior vena cava. From the terms inferior and posterior, one can say that this vein is the heart on the side.

Which of the following is true about the abbreviation CTA?

Which term refers to "before surgery"?

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

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

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

If a person's head were divided on the coronal plane, which of the following is TRUE?

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