Chapter 22 Flashcards

1
Q

Which of the following is the most appropriate action in order to make a correction when an error has been made in the paper chart?

A

Draw a singal line thru the error, then write the correct entry and initial and date.

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2
Q

Which of the following is the most appropriate action in order to make a correction when an error has been made in the EMR?

A

Create an addendum, correcting the error

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3
Q

Which of the following is not a method used for charting?

A

SWISS

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4
Q

Information such as the patient’s full name, address and phone number would be found on what form?

A

Demographic data form

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5
Q

Which part of the medical history includes notes about location, quality and timing.

A

history of present illness

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6
Q

Which review of systems would include joint stiffness, muscle pain, and limited range of motion?

A

Musculoskeletal

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7
Q

Which review of systems would include SOA

A

Respiratory

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8
Q

Which of the following describes the physician’s overall assessment of major body functions?

A

Review of systems

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9
Q

NPO :

A

nothing by mouth

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10
Q

dx

A

diagnosis

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11
Q

prn

A

as needed

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12
Q

a triangle symbol :

A

change

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13
Q

symptoms and patient’s complaints :

A

subjective

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14
Q

diagnosis

A

assesment

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15
Q

further testing and treatment :

A

plan

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16
Q

vital signs :

A

objective

17
Q

expansion of the information that brought the patient to the office :

A

history of present illness

18
Q

all health problems, illnesses, and surgeries :

A

medical history

19
Q

medical problems of siblings and parents :

A

family history

20
Q

occupation, hobbies, and drug habits :

A

social history