Lesson 6

Question 1

Medical history: Significant __________ in the patient’s past

Answer 1

diagnoses

Question 2

Surgical history: Significant __________ the patient has had in the past.

Answer 2

procedures

Question 3

Family medical history: Family members’ __________ (alive, deceased, other) and health risks and diseases

Answer 3

status

Question 4

Social history: A patient’s __________, alcohol, and drug use, as well as __________ activity

Answer 4

tobacco, sexual

Question 5

Define birth history

Answer 5

Details about a patient’s birth, such as birth length and weight, delivery method, and APGAR scores

Question 6

Obstetric history: The (female) patient’s __________ history.

Answer 6

pregnancy

Question 7

What is a Problem List?

Answer 7

A patient’s problem list is a list of concerning diagnoses that are likely to be addressed at upcoming visits. Some problems will never end (diabetes), while
others will end (pregnancy).

Clinicians add diagnoses to a patient’s problem list, and all clinicians involved in that patient’s care share the same list. For a problem diagnosis that has ended, it
must be manually inactivated (resolved).

Question 8

True or False: Significant past diagnoses are documented as medical history.

Answer 8

True

Question 9

True or False: To enter a comment, choose the Medical history diagnosis search field.

Answer 9

False

Question 10

True or False: To enter a date, choose the paper icon pertaining to the diagnosis.

Answer 10

True

Question 11

True or False: To add a diagnosis that is not already in the template, choose the Medical history diagnosis search field.

Answer 11

True

Question 12

True or False: The Date field for medical and surgical history items would accept the words “early childhood” as an entry.

Answer 12

True

Question 13

True or False: Clinicians can each maintain their own problem list for each patient.

Answer 13

False

Question 14

Arm fracture is on a patient’s problem list and has not been an issue for more than a year. For problem list maintenance, what should be done with this diagnosis? (Select one.)
A) Copy it as an encounter (visit) diagnosis.
B) Mark it as resolved.
C) Mark it as deleted.
D) Click Change.

Answer 14

B) Mark it as resolved.

Question 15

Medical history

Answer 15

a narrative or record of past events and circumstances that are or may be relevant to a patient’s current state of health. Informally, an account of past diseases, injuries, treatments, and other strictly medical facts

Question 16

Pertinent negative

Answer 16

If a patient has not had a particular diagnosis or procedure, that information can be pertinent. Therefore, this would be worth noting in the patient’s history as a “pertinent negative.”

Question 17

Distinguish between surgical and medical history

Answer 17

Surgical is any history regarding procedures that have been performed in the past
Medical is any history regarding significant diagnoses in the patient’s past

Question 18

Why is the Date field is free text for medical and surgical history items?

Answer 18

The Date field is free text because patients often cannot remember exact dates.

Question 19

The purpose of, and relationship among: visit diagnoses, problem list diagnoses, and medical history diagnoses

Answer 19

…

Question 20

When to resolve a problem diagnosis

Answer 20

…