The Medical Record

Question 1

What are the 2 most common medical record entries?

Answer 1

Evaluation and management (E/M) documentation and Operative Reports

Question 2

Palpation

Answer 2

Examination of body by touch to look for organ size or condition or tenderness

Question 3

Auscultation

Answer 3

Listening to body sounds

Question 4

Percussion

Answer 4

Creating sounds from tapping on body areas to examine body organs and cavities