Clinical Documentation Ch 3 & 10

Question 1

7 cardinal aspects of the HPI that should be documented in the Subjective Information

Answer 1

Location
Onset
Character
Associated s/s
Timing
Exacerbating/relieving factors
Severity

Question 2

Name pertinent aspects of the PMH that should be documented

Answer 2

past Dx’s, surgeries/hospitalizations, medications, allergies, health maintenance/immunizations

Question 3

What information about the patient’s social history would be important to document?

Answer 3

Smoking hx, drinking hx, occupation, lifestyle, ability to access healthcare, nutritional info, sexual orientation, recent travel, if lived abroad, gender identification, etc

Question 4

Name 5 things that would be documented as subjective information

Answer 4

1. History obtained from spouse
2. Family Hx
3. ROS
4. Medications
5. Onset of CC

Question 5

Name 5 things that would documented in the Plan portion of the HPI

Answer 5

1. Patient education
2. Lab and Xray orders
3. Recommended OTC medications
4. Follow-up instructions
5. Referrals

Question 6

BMP

Answer 6

Basic Metabolic Panel

Question 7

CC

Answer 7

Chief Complaint

Question 8

EMR

Answer 8

Electronic Medical Record

Question 9

GI

Answer 9

Gastrointestinal

Question 10

H&P

Answer 10

History and Physical

Question 11

Hct

Answer 11

Hematocrit

Question 12

Hgb

Answer 12

Hemoglobin

Question 13

ICD-10

Answer 13

International Classification of Diseases-10th Revision

Question 14

OB/GYN

Answer 14

Obestetrics/Gynecology

Question 15

PMH

Answer 15

Past Medical History

Question 16

RICE

Answer 16

Rest, ICE, Compression, Elevate

Question 17

SH

Answer 17

Social History

Question 18

UA

Answer 18

Urine Analysis

Question 19

VS

Answer 19

Vital Signs

Question 20

CBC

Answer 20

Complete Blood Count

Question 21

DDX

Answer 21

Differential Diagnosis

Question 22

FH

Answer 22

Family History

Question 23

GYN

Answer 23

Gynecology

Question 24

HPI

Answer 24

History of Present Illness

Question 25

MRI

Answer 25

Magnetic Resonance Imaging

Question 26

OTC

Answer 26

Over the Counter

Question 27

PRN

Answer 27

As needed

Question 28

RLQ

Answer 28

Right lower quadrant

Question 29

SOAP

Answer 29

Subjective Objective Assessment Plan

Question 30

ROS

Answer 30

Review of Systems

Question 31

UTI

Answer 31

Urinary Tract Infection

Question 32

WBC

Answer 32

White Blood Cell

Question 33

WNL

Answer 33

Within Normal Limits

Question 34

Name the 12 systems that should be documented in the ROS

Answer 34

1. HEENT
2. Cardiovascular
3. Respiratory
4. Gastrointestinal
5. Genitourinary
6. Musculoskeletal
7. Integumentary
8. Neurological
9. Psychiatric
10. Endocrine
11. Hematologic/lymphatic
12. Allergic/immunologic

Question 34

What is the pneumonic used for writing admission orders and what does it stand for?

Answer 34

AD CAVA DIMPLS
Admit
Diagnosis
Condition
Activity
Vital Signs
Allergies
Diet
Interventions
Medications
Procedures
Labs/diagnostic studies
Special instructions

Question 35

ADEs

Answer 35

Adverse Drug Events

Question 36

BMP

Answer 36

Basic Metabolic Panel

Question 37

BR

Answer 37

Bed Rest

Question 38

CAD

Answer 38

Coronary Artery Disease

Question 39

CC

Answer 39

Chief Complaint

Question 40

CMS

Answer 40

Center for Medicare and Medicaid Services

Question 41

CPOE

Answer 41

Computerized Physician Order Entry

Question 42

D5NS

Answer 42

Dextrose 5% Normal Saline

Question 42

CVA

Answer 42

Cerebrovascular Accident

Question 43

ED

Answer 43

Emergency Department

Question 44

EMR

Answer 44

Electronic Medical Record

Question 45

H&H

Answer 45

Hematocrit and hemoglobin

Question 46

HHS

Answer 46

Health and Human Services

Question 47

HR

Answer 47

Heart Rate

Question 48

I&O

Answer 48

Intake & Output

Question 49

ISMP

Answer 49

Institute for Safe Medication Practices

Question 50

IV

Answer 50

Intravenous

Question 51

NPSG

Answer 51

National Patient Safety Goal

Question 52

OCR

Answer 52

Office of Civil Rights

Question 53

PACU

Answer 53

Post Anesthesia Care Unit

Question 54

PCP

Answer 54

Primary Care Provider

Question 55

PRN

Answer 55

As needed

Question 56

RLL

Answer 56

Right lower lobe

Question 57

RR

Answer 57

Respiratory rate

Question 58

S/P

Answer 58

Status Post

Question 59

T

Answer 59

Temperature

Question 60

VS

Answer 60

Vital Signs

Question 61

WNL

Answer 61

Within Normal Limits

Question 62

AMI

Answer 62

Acute Myocardial Infarction

Question 63

AP

Answer 63

Anterior Posterior

Question 64

BP

Answer 64

Blood Pressure

Question 65

BRP

Answer 65

Bathroom Privileges

Question 66

CBC

Answer 66

Complete Blood Count

Question 67

CDSS

Answer 67

Clinical Decision Support System

Question 68

COPD

Answer 68

Chronic Obstructive Pulmonary Disease

Question 69

CT

Answer 69

Computed Tomography

Question 70

CXR

Answer 70

Chest Xray

Question 71

ECG

Answer 71

Electrocardiogram

Question 72

E/M

Answer 72

Evaluation & Management

Question 73

FH

Answer 73

Family History

Question 74

H&P

Answer 74

History and Physical

Question 75

HPI

Answer 75

History of Present Illness

Question 76

HTN

Answer 76

Hypertension

Question 77

IS

Answer 77

Incentive Spirometry

Question 78

IT

Answer 78

Information Technology

Question 79

NPO

Answer 79

Nothing by mouth

Question 80

NS

Answer 80

Normal Saline

Question 81

OOB

Answer 81

Out of Bed

Question 82

PCA

Answer 82

Patient Controlled Analgesia

Question 83

PMH

Answer 83

Past Medical History

Question 84

PT

Answer 84

Physical therapy

Question 85

ROS

Answer 85

Review of Systems

Question 86

SH

Answer 86

Social History

Question 87

SVN

Answer 87

Small volume nebulizer

Question 88

TID

Answer 88

Three times per day

Question 89

WBC

Answer 89

White blood cells