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HEAL210 > Chapter 22 > Flashcards

Chapter 22 Flashcards

1
Q

Which of the following best describes the patient’s idea of treatment success?

a. Understanding the physiology of the disease	
b. Getting medications	
c. Being able to successfully manage the disease	
d. Understanding what caused the illness	
e. Curing the disease
A

c. Being able to successfully manage the disease

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2
Q

Which of the following best describes the first responsibility of the medical assistant when taking the medical history?

a. Wash hands.	
b. Allow freedom of conversation.	
c. Obtain personal information first.	
d. Put the patient at ease.	
e. Follow the exact order of the history form.
A

d. Put the patient at ease.

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3
Q

Which of the following is the most appropriate action when the patient comes into the office for a singular problem and wants to discuss many problems with the physician?

a. List all the problems under chief complaint.	
b. Remind the patient that the physician’s time is limited, but he will try and accommodate if possible.	
c. Tell the patient more time is needed and reschedule the appointment.	
d. Tell the patient not to worry because the physician will meet all his needs.
A

b. Remind the patient that the physician’s time is limited, but he will try and accommodate if possible.

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4
Q

Which of the following statements is true about interviewing?

a. Allow the patient to tell anecdotes.	
b. Do not worry about comfort level.	
c. Guide the conversation and keep it on track.	
d. Do not waste time explaining terms or concepts.
A

c. Guide the conversation and keep it on track.

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5
Q

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

a. Review of symptoms	
b. History present illness	
c. Past medical history	
d. Family history	
e. Social history
A

b. History present illness

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6
Q

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

a. Family history	
b. Social history	
c. Review of systems	
d. Past medical history	
e. Disease examination
A

c. Review of systems

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7
Q

Which of the following best describes the format of a source-oriented medical record?

a. Notes written in SOAP format	
b. Database, problem list, and examination	
c. All the objective materials gathered about the patient	
d. Chronological set of notes for each visit
A

d. Chronological set of notes for each visit

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8
Q

Which of the following is the most appropriate action when the medical assistant is taking the medical history?

a. Be firm and inflexible.	
b. Use medical jargon when possible.	
c. Ask intimate questions right away to get them over with.	
d. Ask the patient whether there are any questions.
A

d. Ask the patient whether there are any questions.

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9
Q

Which of the following is the most appropriate action for the medical assistant with the uncommunicative patient?

a. Let the physician interview the patient.	
b. Inform the patient of guidelines for expected behavior.	
c. Give the patient a sample problem list to review.	
d. Tell the patient that cooperation is mandatory.
A

c. Give the patient a sample problem list to review.

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10
Q

Which of the following is the most appropriate action of the medical assistant when asking a patient about sensitive topics such as alcohol or drug use?

a. Be judgmental when necessary.	
b. Do not make eye contact.	
c. Ask sensitive questions at the beginning to get uncomfortable moments over.	
d. Wait until a good rapport with the patient is established before asking sensitive questions.
A

d. Wait until a good rapport with the patient is established before asking sensitive questions.

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11
Q

What should the medical assistant do if a patient refuses to answer a question regarding sexual history during the patient interview?

a. Wait until the patient is ready to answer.	
b. Skip the question completely.	
c. Attempt to return to the question later.	
d. Force the issue and ask for answers
A

c. Attempt to return to the question later.

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12
Q

Which of the following components of the review of systems includes joint stiffness, muscle pain, and limitation of movement?

a. Nervous	
b. Gastrointestinal	
c. Cardiovascular	
d. Respiratory	
e. Musculoskeletal
A

e. Musculoskeletal

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13
Q

Which of the following components of the review of systems would include change in speech?

a. Musculoskeletal	
b. Gastrointestinal	
c. Respiratory	
d. Neurological	
e. Cardiovascular
A

d. Neurological

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14
Q

Which of the following components of the review of systems would include shortness of breath?

a. Cardiovascular	
b. Musculoskeletal	
c. Nervous	
d. Respiratory	
e. Gastrointestinal
A

d. Respiratory

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15
Q

Which of the following is NOT a common medical records format?

a. None of the above	
b. Source-oriented	
c. Patient-oriented	
d. Problem-oriented
A

c. Patient-oriented

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16
Q

Which of the following best describe the major components of the problem-oriented medical record?

a. Problem list, diagnostic and treatment plan, progress notes	
b. Database, problem list, diagnostic and treatment plan, progress notes	
c. Database, problem list, diagnostic and treatment plan, laboratory reports	
d. Database, problem list, diagnostic and treatment plan	
e. Problem list, diagnostic and treatment plan, progress notes, laboratory reports
A

b. Database, problem list, diagnostic and treatment plan, progress notes

17
Q

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

a. Draw a single line through the error. Write the correct entry and put initials and date.	
b. Scribble out the error and write above it.	
c. Erase the error and correct it.	
d. Cover with Wite-Out®, write over it, and initial and date it.
A

a. Draw a single line through the error. Write the correct entry and put initials and date.

18
Q

What is the correct order for information placed chronologically in the chart?

a. Primary providers notes, laboratory reports, pathology reports, hospital notes	
b. Primary providers notes, laboratory reports, pathology reports, consultations	
c. Primary providers notes, hospital notes, laboratory reports, medications	
d. Primary providers notes, EKGs and x-rays, hospital notes, consultations, correspondence	
e. Primary providers notes, EKGs and x-rays, laboratory reports, pathology reports
A

d. Primary providers notes, EKGs and x-rays, hospital notes, consultations, correspondence

19
Q

Which of the following is NOT a purpose for the patient’s medical history?

a. Gives a base for statistical analysis	
b. Allows the provider to recall previous treatment	
c. Helps guide the patient’s treatment	
d. Allows the patient to help with the diagnosis
A

d. Allows the patient to help with the diagnosis

20
Q

You have picked up your equipment and the supplies necessary to obtain a medical history from a new patient. You introduce yourself to the patient after confirming her identity. Then you attempt to put her at ease. What is the next thing you should do?

a. Explain the purpose and importance of information gathering.	
b. Ask about allergies.	
c. Wash your hands.	
d. Begin to ask questions.
A

a. Explain the purpose and importance of information gathering.

21
Q

When you ask the patient questions in the history interview, what is the MOST important consideration?

a. That the patient be allowed to decline to answer	
b. That all questions be repeated	
c. That the patient answer each question	
d. That the patient understand each question
A

d. That the patient understand each question

22
Q

Which is considered the physician’s chief concern?

a. Illness	
b. Treatment	
c. Medication	
d. Disease
A

d. Disease

23
Q

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

a. Financial information form	
b. Medical history form	
c. Demographic data form	
d. Insurance form
A

c. Demographic data form

24
Q

Which of the following is NOT included on the patient’s medical history form?

a. Social history	
b. Body systems review	
c. Present health history	
d. Insurance history
A

d. Insurance history

25
Q

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

a. SOAPER	
b. SWISS	
c. SOAP	
d. CHEDDAR
A

b. SWISS

26
Q

In the SOAPER charting method, what does the letter “E” represent?

a. Early history	
b. Education	
c. Elaboration	
d. Examination
A

b. Education

27
Q

Which is NOT a vulnerable area that HIPAA regulations focus on in regard to medical records and the patient’s chart?

a. Photocopies	
b. Paper record storage	
c. Workstations	
d. Fax machines
A

a. Photocopies

HEAL210 (9 decks)

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