Medical Recors Types Flashcards
Social History would include a patient’s smoking background.
True
Emergency room reports usually follow the SOAP format
False
The review of systems usually comes after the Physical Examination section of most medical reports
False
Radiology reports include only cheat x-rays and MRI reports
False
A report dictated by a physician other than the attending physician is called a consultation
True
Specific details of the doctor’s exam of a patient appear in the subjective portion of a clinic note
False
Operative reports are generally not dictated when the operation is considered minor.
False
All procedures performed during a hospital stay should be included in the discharge summary
True
A history and physical report is never done in an acute care setting
False
Which subheading would “the patient takes Tylenol and Plavix” be placed under
Current Medications
Which subheading would “ the heart has a regular rate and rhythm” be placed under?
Heart section of Physical Examination
Which subheading work “history of diabetes mellitus” be placed under?
Past medical history
What subheading would “the blood pressure is 120/84” be placed under?
Vital signs section of physical examination
What subheading would “excision of a cyst from the upper back” be placed under
Procedure
What subheading would “on the third hospital day, the patient experienced syncope” be placed under
Hospital course
