Chapter 5: Documentation Flashcards
During the course of the interview, you should: a. take no notes of any kind. b. take brief written notes. c. take detailed written notes. d. repeat pertinent comments into a Dictaphone. e. interrupt the interview to formulate your thoughts.
ANS: B During the interviewing process, it is important to maintain eye contact with the patient and to spend as little time as possible looking at your notes, so brief written notes are more practical. Later you can go back and formulate a well-versed history by linking all the pieces together.
Subjective and symptomatic data are: a. documented in your assessment. b. not mentioned in the legal chart. c. placed in the history sections. d. recorded with the examination technique. e. documented with the findings.
ANS: C Subjective data, as well as symptomatic data, should not be part of the physical examination findings; rather, their documentation is appropriate for the history portion.
The quality of a symptom, such as pain, is subjective information that should be: a. deferred until the cause is determined. b. described in the history using a 0 to 10 scale. c. placed in the past medical history section. d. placed in the history with objective data. e. interpreted in light of your physical findings.
ANS: B Pain is subjective, and only the patient can rate the perceived severity. Pain, therefore, should be recorded in the history using a 0 to 10 scale.
Drawing of stick figures is most useful to: a. compare findings in the extremities. b. demonstrate radiation of pain. c. indicate organ enlargement. d. indicate mobility of masses. e. indicate consistency of lymph nodes.
ANS: A Simple drawings, such as stick figures, are more practical illustrations for findings in the extremities. Radiation of pain, organ enlargement, consistency of lymph nodes, and mobility of masses would not be adequately described by such simple drawings.
Which of the following is an example of a problem requiring recording on the patient’s problem list? a. Common age variations b. Expected findings c. Findings of unknown origin d. Minor variations e. Only findings that have a clear etiology
ANS: C Any problem is worth noting on the patient problem list even if the etiology or significance is unknown. Common age variations, expected findings, and minor variations within normal limits should not be classified as problems.
Differential diagnoses belong in the: a. history. b. physical examination. c. assessment. d. plan. e. laboratory data.
ANS: C Differential diagnoses for problems that have not been diagnosed are placed in the assessment category for each problem. The differentials are prioritized, and contributing factors are identified.
When recording assessments during the construction of the problem-oriented medical record, the examiner should: a. combine all data into one assessment. b. create an assessment for each problem on the problem list. c. create an assessment for every abnormal physical finding. d. create an assessment for every symptom presented in the history. e. create an assessment for each abnormal laboratory finding.
ANS: B After the examiner has a list of problems constructed, an assessment is made for each unique problem.
Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n): a. progress note. b. incident report. c. problem-oriented medical record. d. triage note. e. new problem list.
ANS: A A second visit with the clinician is always recorded on a progress note, noting any updates to the condition.
The effect of the chief concern on the patient’s lifestyle is recorded in which section of the medical record? a. Chief complaint b. History of present illness c. Past medical history d. General patient information e. Social history
ANS: B The effect of the patient’s complaint on his or her current everyday lifestyle or work performance is recorded in the history of present illness.
The patient’s perceived disabilities and functional limitations are recorded in the: a. problem list. b. general patient information. c. social history. d. review of systems. e. past medical history.
ANS: E Past medical history contains information about the patient’s lifetime as well as disabilities or functional limitations that alter activities of daily living. TOP: Discipline: Behavioral
The review of systems is a component of the: a. physical examination. b. health history. c. assessment. d. past medical and surgical history. e. personal and social history.
ANS: E Review of systems relates health history according to physical systems and is related just before the actual physical examination.
Allergies to drugs and foods are generally listed in which section of the medical record? a. General patient information b. Past medical history c. Social history d. Problem list e. History of present illness
ANS: B The past medical history section contains information such as drugs, foods, and environmental allergies.
Objective data are usually recorded: a. by body systems. b. in the history. c. subsequent to the assessment and plan. d. before the health history. e. in the problem list.
ANS: A All objective data are recorded by body systems and anatomic locations.
Information recorded about an infant differs from that of an adult, mainly because of the infant’s: a. attention span. b. developmental status. c. nutritional differences. d. source of information. e. limited past medical history.
ANS: B The organizational structure of an infant’s record is different because the infant’s current and future health is referenced in terms of developmental status.
In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data? a. Family b. General patient information c. Personal and social d. Present problem e. Past medical
ANS: D For a newborn, the focus of recorded information is the details of the mother’s pregnancy, the gestational development, and events occurring since birth. These data are recorded in the present problem section of the history.
Data relevant to the social history of older adults include information on: a. family support systems. b. extra time to assume positions. c. over-the-counter medication intake. d. date of last cancer screening. e. previous healthcare visits.
ANS: A The social history of older adults includes community and family support systems. Healthcare visits, medications, cancer screenings, and extra time to assume positions for the physical examination are not part of the social history.
A SOAP note is used in which type of recording system? a. Preventive care b. Pedigree c. Systems review d. Traditional treatment e. Problem oriented
ANS: E A SOAP note, which includes subjective problem data, objective problem data, assessment, and plan, is a type of recording system that has a problem-oriented style.
