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Medical Terminology > Intoduction To Health Records > Flashcards

Intoduction To Health Records Flashcards

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USMLE® Step 1 flashcards
1
Q

Forming a logical analysis is in the _________ part of the SOAP method.

A

Assessment

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2
Q

What would be included in the subjective section of a health record?

A

Current medication’s; timing of the problem; reason for the visit

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3
Q

Correct documentation and a patient’s chart can prevent which of the following?

A

Adverse outcomes; potentially fatal outcomes

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4
Q

A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health is the …

A

Social history

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5
Q

Data compiled through laboratory findings is considered…

A

Objective

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6
Q

What are acceptable methods of documentation in a patient’s chart?

A

Dictated, electronic, handwritten

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7
Q

The _______ section of a health record tells the patients story of their health issues.

A

Subjective

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8
Q

What type of documentation format is used for consultation notes?

A

SOAP

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9
Q

Who are specially trained in, treating patients respiratory issues under the guidance of a healthcare provider?

A

Respiratory therapist

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10
Q

Most patients seen by the medical staff in an emergency department are what type of patients?

A

New

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11
Q

Subjective

A

Blue

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12
Q

Objective

A

Red

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13
Q

Assessment

A

Yellow

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14
Q

Plan

A

Green

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15
Q

Afebrile

A

To not have a fever

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16
Q

Progressive

A

More and more each day

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17
Q

Symptom

A

Something a patient feels

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18
Q

Lethargic

A

A decrease in level of consciousness

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19
Q

After the medical history, history is obtained the physical exam is completed, the attending medical professional rights a detailed…

A

Admission summary

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20
Q

Consultation notes are written by the consulting physician, and sent to the…

A

PCP

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21
Q

What is documented in the discharge summary of a patient?

A

What types of follow up are required; how patient felt when admitted; what happened during patient’s stay at the hospital

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22
Q

What type of information is recorded on the emergency department note?

A

Plan of care; patient assessment; diagnostic tests

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23
Q

Which physicians document the operative report on the patient?

A

Surgeon

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24
Q

The main reason for the patient visit is the…

A

Chief complaint

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25
Q

What is the name of the report documented by the healthcare provider who assesses the patient’s care each day?

A

Progress note; daily report

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26
Q

What type of report explains the reason for ordering a radiologic image?

A

Radiology

27
Q

The assessment is also known as a(an)…

A

Differential diagnosis

28
Q

A discharge summary note details ______ and _______ a patient is admitted.

A

When; why

29
Q

A pathology report is very similar to which type of report?

A

Radiology report

30
Q

Name the report documented after a surgery was performed by a surgeon

A

Operative report

31
Q

What documentation is a focus on the daily report/progress note

A

Subjective part

32
Q

What is documented on the radiology report?

A

How image was performed; reason image was ordered; radiologist assessment

33
Q

The prescription form is documented in the _______ part of the SOAP method

A

Plan

34
Q

What parts of the SOAP method or heavily used to document and admission summary?

A

Objective; subjective

35
Q

What is mentioned in a pathology report?

A

What was seen in detail; reason for the study; pathologist’s assessment

36
Q

Abbreviation for bilateral

A

(B)

37
Q

Which physicians documents the operative report on the patient?

A

Surgeon 

38
Q

What abbreviation means after meals?

A

PC

39
Q

How often are progress notes documented in the patient’s chart?

A

Daily

40
Q

The second line of the prescription, which provides the patient’s instructions, is the…

A

Sig.

41
Q

What abbreviation means daily?

A

QD

42
Q

The prescription form is documented in the __________ part of the SOAP method.

A

Plan

43
Q

Subjective

A

A description of the problem in the patients own words

44
Q

Plan

A

Treatment with medicine or a procedure

45
Q

Objective

A

Data collected to assist in understanding the nature of the problem

46
Q

Assessment

A

Cause of the problem

47
Q

Medical professionals directions for a patient’s medication

A

Prescription

48
Q

Documents a patient’s emergency department visit

A

Emergency department note

49
Q

Documents a patient’s progress during a daily hospital visit

A

Daily hospital note/progress note

50
Q

Documents and imaging procedure by a radiologist

A

Radiology report

51
Q

Documents a pathology procedure

A

Pathology report

52
Q

Documents a patient’s admission to the hospital

A

Admission summary

53
Q

Documents a surgery

A

Operative report

54
Q

Documents a patient’s visit in an office setting

A

Clinic note

55
Q

Documents sent to a primary position, usually specialist, to give an opinion on the more challenging problem

A

Consult note

56
Q

Documents a patient’s admission and hospital stay (usually a longer stay)

A

Discharge summary

57
Q

Any past surgeries

A

Past surgical history

58
Q

Mainly health habits, like smoking, drinking, drug use, or sexual practices

A

Social history

59
Q

The story of the patient’s problem

A

History of present illness

60
Q

Any significant illness that runs in the patient’s family

A

Family history

61
Q

Other significant past illnesses, like high blood pressure, asthma, or diabetes

A

Past medical history

62
Q

The main reason for a visit

A

Chief complaint

63
Q

Any symptoms not directly related to the main problem

A

Review of systems

Medical Terminology (4 decks)

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