Chapter 5 Health Record Flashcards
Which part of the information contained in the patient’s record may be used in court?
a. Subjective information only
b. Objective information only
c. Diagnostic information only
d. All information
ANS: D
Anything that is entered into a patient’s record, in paper or electronic form, is a legal
document and can be used in court.
Ms. S reports that she is concerned about her loss of appetite. During the history, you learn
that her last child recently moved out of her house to go to college. Rather than infer the cause
of Ms. S’s loss of appetite, it would be better to
a. defer or omit her comments.
b. have her husband call you.
c. quote her concerns verbatim.
d. refer her for psychiatric treatment.
ANS: C
It is best to document what you observe and what is said by the patient rather than
documenting your interpretation. Listening and quoting exactly what the patient says is the
better rule to follow.
Which is an effective adjunct to document the location of findings during the recording of the
physical examination?
a. Relationship to anatomic landmarks
b. Computer graphics
c. Comparison with other patients of same gender and size
d. Comparison to previous examinations using light pen markings
ANS: A
Abnormal or normal findings are best described in relationship to universal topographic and
anatomic landmarks.
The position on a clock, topographic notations, and anatomic landmarks
a. are methods for recording locations of findings.
b. are used for noting disease progression.
c. are ways for recording laboratory study results.
d. should not be used in the legal record.
ANS: A
Descriptions of the locations of findings are universally referenced by using positions on a
clock, topographic notations, or anatomic landmarks.
Regardless of the origin, discharge is described by noting
a. a grading scale of 0 to 4.
b. color and consistency.
c. demographic data and risk factors.
d. associated symptoms in alphabetic order.
ANS: B
Regardless of where the discharge originates, color and consistency determine whether it is an
expected finding.
Drawing of stick figures is most useful to
a. compare findings in extremities.
b. demonstrate radiation of pain.
c. indicate consistency of lymph nodes.
d. indicate mobility of masses.
ANS: A
Simple drawings, such as stick figures, are more practical illustrations for findings in
extremities. Radiation of pain, consistency of lymph nodes, and mobility of masses would not
be adequately described by such simple drawings.
Which is an example of a problem that requires recording on the patient’s problem list?
a. Common age variations
b. Expected findings
c. Problems needing further evaluation
d. Minor variations
ANS: C
Any problem is worth noting on the patient problem list, even if the cause or significance is
unknown. Common age variations, expected findings, and minor variations within normal
limits should not be classified as a problem.
A problem may be defined as anything that will require
a. evaluation.
b. medication.
c. surgery.
d. treatment.
ANS: A
The need for further evaluation or attention indicates a problem. If a problem is found, it does not necessarily warrant medication, surgery, or treatment.
Differential diagnoses belong in the
a. history.
b. physical examination.
c. assessment.
d. plan.
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
Which of the following is not a component of the plan portion of the problem-oriented
medical record?
a. Diagnostics ordered
b. Therapeutics
c. Patient education
d. Differential diagnosis
ANS: D
The differential diagnosis is part of the assessment phase
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. accident report.
c. problem-oriented medical record.
d. triage note.
ANS: A
A second visit with the clinician is always recorded on a progress note, noting any updates to
the condition.
A detailed description of the symptoms related to the chief complaint is presented in the
a. history of present illness.
b. differential diagnosis.
c. assessment.
d. general patient information section.
ANS: A
The signs and symptoms and historical data of the patient’s experience that led up to the chief
complaint are placed in the history of present illness.
The effect of the chief complaint 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. Social history
ANS: B
The effect of the patient’s complaint on 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. history of present illness.
ANS: D
The history of present illness contains information about the patient’s lifestyle, as well as
disabilities or functional limitations that alter activities of daily living.
The review of systems is a component of the
a. physical examination.
b. health history.
c. assessment.
d. past medical-surgical history.
ANS: B
The review of systems relates health history according to physical systems and is presented
just before the actual physical examination.
