Patient Assessment Flashcards
The section of medical history that uncovers existing or potential health problems
Systems Review
Symptom
Only what the patient can tell you. You can not see it.
Medical record system that has a standard format that makes it easy to read and audit
Problem Oriented
Database
Includes insurance information and demographic information
ROS
Includes the physical examination finding
Reflection
Repeating or paraphrasing the patient’s comments. Stating an observation or recognition of a patient’s feelings
Clarification
Asking a question or summarizing a patient’s thoughts
Closed Question
Yes or no
Information that you gather from a patient interview is considered…
Subjective
Blood pressure recording is considered…
Objective
The medical assistant is responsible for documenting all of the following information except the…
Review of systems
Sign
Can be seen
Which of the following components of the medical history provide a guide to the patient’s general health
Systems Review
Involves active listening seeks to summarize or simplify the senders thoughts and feelings or to resolve any confusion in the message
Clarification
Learned behaviors that are greatly influenced by our family and cultural backgrounds…
Nonverbal communication
Difficulty breathing is a _________ finding
Subjective
When writing progress (SOAP) notes, in which section would the providers preliminary diagnosis of the cause of the patient chief complaint be placed…
Assessment
Stage 3 requirement for Medicare and Medicaid EHR Incentive Program?
Providers are expected to show improved patient outcomes
Which type of data collection is NOT associated with holistic care?
Social
When a verbal message matches the senders nonverbal body language, the message is considered….
Congruent
During the _________ phase of the interview, MA should introduce themselves and state the purpose of the interview
Initation
The __________ of the interview should summarize the info the MA learned while communicating and should outline patient expectations of care
Closing
Subjective reports given by the patient on how they feel
Subjective
________ data include the patient’s blood pressure, TPR, and weight
Objective
Plan
The physician approach to managing the patient’s health problem
When SOAPE documentation is used, the ________ documentation provides feedback on the result of treatment
Evaluation
The ________ in POMR chart lists the patient diagnoses in chronologic order
Problem list
The physician initial impression of what is wrong with the patient is called the ________ diagnoses
Working
Component of the medical history contains detail about insurance, address, and date of birth
Database
Detail how to make a correction in a patient’s paper record
Straight line, initials, date, or time
