Chapter 2 (Health Record Notes)

Question 1

clinic note

Answer 1

documentation of a visit, written by professional at a clinic (includes SOAP)

Question 2

consult note

Answer 2

provides an expert opinion on a more challenging problem, written by a specialist at a clinic or hospital (includes SOAP)

Question 3

emergency department note

Answer 3

documents an emergency department visit, written by an ED medical staff at an emergency department (includes SOAP)

Question 4

admission summary

Answer 4

documents the admission of a patient to the hospital, written by a medical professional at a hospital (includes SO A/P)

Question 5

discharge summary

Answer 5

describes when and why the patient was admitted, written by a medical professional at a hospital (includes ASOP; starts with A)

Question 6

operative report

Answer 6

documents a surgery in detail, written by a surgeon (includes ASOP; starts with A)

Question 7

daily hospital note / progress report

Answer 7

documents daily hospital visit, written by medical professional (includes SO A/P)

Question 8

radiology report

Answer 8

explains reason for image, how image was performed, what was seen on the image, and the radiologist’s assessment, written by a radiologist (includes SOA)

Question 9

pathology report

Answer 9

provides reasons for test, what was seen on the test, and an assessment, written by a pathologist (includes SOA)

Question 10

prescription

Answer 10

provides directions for a medication, written by a medical professional (includes P)