Patient Assessment

Question 1

The section of medical history that uncovers existing or potential health problems

Answer 1

Systems Review

Question 2

Symptom

Answer 2

Only what the patient can tell you. You can not see it.

Question 3

Medical record system that has a standard format that makes it easy to read and audit

Answer 3

Problem Oriented

Question 4

Database

Answer 4

Includes insurance information and demographic information

Question 5

ROS

Answer 5

Includes the physical examination finding

Question 6

Reflection

Answer 6

Repeating or paraphrasing the patient’s comments. Stating an observation or recognition of a patient’s feelings

Question 7

Clarification

Answer 7

Asking a question or summarizing a patient’s thoughts

Question 8

Closed Question

Answer 8

Yes or no

Question 9

Information that you gather from a patient interview is considered…

Answer 9

Subjective

Question 10

Blood pressure recording is considered…

Answer 10

Objective

Question 11

The medical assistant is responsible for documenting all of the following information except the…

Answer 11

Review of systems

Question 12

Sign

Answer 12

Can be seen

Question 13

Which of the following components of the medical history provide a guide to the patient’s general health

Answer 13

Systems Review

Question 14

Involves active listening seeks to summarize or simplify the senders thoughts and feelings or to resolve any confusion in the message

Answer 14

Clarification

Question 15

Learned behaviors that are greatly influenced by our family and cultural backgrounds…

Answer 15

Nonverbal communication

Question 16

Difficulty breathing is a _________ finding

Answer 16

Subjective

Question 17

When writing progress (SOAP) notes, in which section would the providers preliminary diagnosis of the cause of the patient chief complaint be placed…

Answer 17

Assessment

Question 18

Stage 3 requirement for Medicare and Medicaid EHR Incentive Program?

Answer 18

Providers are expected to show improved patient outcomes

Question 19

Which type of data collection is NOT associated with holistic care?

Answer 19

Social

Question 20

When a verbal message matches the senders nonverbal body language, the message is considered….

Answer 20

Congruent

Question 21

During the _________ phase of the interview, MA should introduce themselves and state the purpose of the interview

Answer 21

Initation

Question 22

The __________ of the interview should summarize the info the MA learned while communicating and should outline patient expectations of care

Answer 22

Closing

Question 23

Subjective reports given by the patient on how they feel

Answer 23

Subjective

Question 24

________ data include the patient’s blood pressure, TPR, and weight

Answer 24

Objective

Question 25

Plan

Answer 25

The physician approach to managing the patient’s health problem

Question 26

When SOAPE documentation is used, the ________ documentation provides feedback on the result of treatment

Answer 26

Evaluation

Question 27

The ________ in POMR chart lists the patient diagnoses in chronologic order

Answer 27

Problem list

Question 28

The physician initial impression of what is wrong with the patient is called the ________ diagnoses

Answer 28

Working

Question 29

Component of the medical history contains detail about insurance, address, and date of birth

Answer 29

Database

Question 30

Detail how to make a correction in a patient’s paper record

Answer 30

Straight line, initials, date, or time