Question 1

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

Accepted Answer

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. C

Question 2

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

Accepted Answer

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

Question 3

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

Accepted Answer

Subjective: Any information or facts that the patient presents or that the chart provides. Objective: Data and information obtained by the examiner with his or her eyes, ears, and hands. Assessment: Pulls together the findings presented in the subjective and objective sections to form a diagnosis. Plan: Outlines the treatment plan. Each step builds chronologically on the previous one.

Question 4

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

Accepted Answer

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

Question 5

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

Accepted Answer

A) True 
 B)False

Question 6

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

Accepted Answer

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

Question 7

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

Accepted Answer

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.

Question 8

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

Accepted Answer

The answer of What are the five broad categories usually...

Question 9

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

Accepted Answer

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 10

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

Accepted Answer

A) True 
 B)False

Question 11

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.

Accepted Answer

A) True 
 B)False

Question 12

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

Accepted Answer

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 13

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.

Accepted Answer

A) True 
 B)False

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.

Accepted Answer

A) True 
 B)False

Question 15

"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.

Accepted Answer

A) True 
 B)False

Question 16

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

Accepted Answer

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

Question 17

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

Accepted Answer

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

Question 18

What is a genogram?

Accepted Answer

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 19

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

Accepted Answer

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 20

SOAP stands for:

Accepted Answer

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

Exam 3: Documentation Strategies

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

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

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

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

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

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

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

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

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

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

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.

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

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.

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.

"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.

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

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

What is a genogram?

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

SOAP stands for: