Chapter 5: Recording Information: Documentation

Question 1

Regarding another provider’s documented work, it:
Select one:
a. is not relevant in a legal proceeding.

b. will not affect clinical decisions.
c. may be copied verbatim into your documentation.
d. must be attributed to the source if entered.
e. does not affect patient care.

Answer 1

d. must be attributed to the source if entered.

Question 2

Which of the following abbreviations is approved by The Joint Commission on Accreditation of Hospitals?

Select one:

a. U (unit)
b. qd (daily)
c. MS (morphine sulfate)
d. All of the above
e. None of the above

Answer 2

b. qd (daily)

Question 3

Data relevant to the social history of older adults include information on:

Select one:

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.

Answer 3

a. family support systems.

Question 4

Allergies to drugs and foods are generally listed in which section of the medical record?

Select one:

a. General patient information
b. Past medical history
c. Social history
d. Problem list
e. History of present illness

Answer 4

b. Past medical history

Question 5

A pedigree diagram is drafted for the purpose of obtaining:

Select one:
a. sexual orientation and history.
b. growth and developmental status.
c. genetic and familial health problems.
d. ethnic and cultural backgrounds.
e.
 the past medical history.

Answer 5

c. genetic and familial health problems.

Question 6

Which of the following is an example of a problem requiring recording on the patient’s problem list?
Select one:
a. Common age variations

b. Expected findings
c. Findings of unknown origin.

d. Minor variations
e. Only findings that have a clear etiology

Answer 6

c. Findings of unknown origin.

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.

Question 7

To what extent should the patient with a physical disability or emotional disorder be involved in providing health history information to the health professional?
Select one:
a. All information should be obtained from family members.
b. All information should be collected from past records while the patient is in another room.
c. The patient should be involved only when you sense that he or she may feel ignored.
d. The patient should be fully involved to the limit of his or her ability.
e. The patient should be present during information collection but should not be addressed directly.

Answer 7

d. The patient should be fully involved to the limit of his or her ability.

Question 8

The patient’s perceived disabilities and functional limitations are recorded in the:

Select one:

a. problem list. Incorrect
b. general patient information.
c. social history.
d. review of systems.
e. past medical history.

Answer 8

e. past medical history.

Question 9

The quality of a symptom, such as pain, is subjective information that should be:

Select one:

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.

Answer 9

b. described in the history using a 0 to 10 scale.

Question 10

When taking a history, you should:

Select one:

a. ask patients to give you any information they can recall about their health.
b. start the interview with the patient’s family history.
c. use a chronologic and sequential framework.
d. use a holistic and eclectic structure.
e. start the interview with the social history.

Answer 10

c. use a chronologic and sequential framework.

To give structure to the present problem or chief concern, the provider should proceed in a chronologic and sequential framework. Asking patients to give you any information they can recall about their health and using a holistic and eclectic structure do not provide for structure. Starting the interview with the patient’s family history and with the social history are incorrect because gathering data about the chief concern is the initial step.

Question 11

A SOAP note is used in which type of recording system?

Select one:
a. note is used in which type of recording system?
Preventive care 
b. Pedigree
c. Systems review
d. Traditional treatment
e. Problem oriented

Answer 11

e. Problem oriented

Question 12

Milestone achievements are data most likely to appear in the history of:
Select one:
a. adolescents.
b. infants. 
c. school-age children.
d. young adults.
e.

 older adults.

Answer 12

b. infants.

Question 13

nformation recorded about an infant differs from that of an adult, mainly because of the infant’s:
Select one:
a. attention span.
b. developmental status 
c. nutritional differences.
d. source of information.
e. limited past medical history.

Answer 13

b. developmental status

Question 14

Drawing of stick figures is most useful to:
Select one:
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.

Answer 14

a. compare findings in the extremities