Unit 4 Medical Record Documentation

Question 1

An imaginary plane that extends the length of the body, dividing it into equal
right and left portions

Answer 1

Mid-sagittal plane

Question 2

An imaginary plane that extends the width of any portion of the body dividing it into upper and lower portions

Answer 2

Transverse plane

Question 3

An imaginary plane that extends the length of the body dividing the body into front and back portions

Answer 3

Coronal plane

Question 4

Is the beginning of an extremity or a system

Answer 4

Point of
origin

Question 5

Directional terms associated with the point of origin are

Answer 5

proximal and distal

Question 6

Means affecting only one side of the body or one of a pair of body organs

Answer 6

unilateral

Question 7

Means affecting both sides of the body or both pairs of body organs

Answer 7

bilateral

Question 8

Movement toward the mid-line of the body

Answer 8

Adduction

Question 9

Movement away from the mid-line of the body

Answer 9

Abduction

Question 10

Movement to close an angle such as the arm movement in a salute

Answer 10

Flexion

Question 11

Movement to open an angle such as reaching out with your arm to turn on a light

Answer 11

Extension

Question 12

Moral principles or values held by a group, person, or profession

Answer 12

ethics

Question 13

The established standards of behavior to be followed by everybody within a specific group, such as the
health care professions

Answer 13

ethical behavior

Question 14

Which Air Force instruction (AFI) covers the release of medical and other personal information?

Answer 14

AFI 33–332, Air Force Privacy and Civil Liberties Program

Question 15

Health records are the property of the

Answer 15

United States government

Question 16

The prefix “20” in front of a social security number on a medical record indicates the record is for the

Answer 16

sponsor

Question 17

The prefix “30” in front of a social security number on a medical record indicates the record is for the

Answer 17

spouse

Question 18

The prefix “01” and so on in front of a social security number on a medical record indicates the record is for the

Answer 18

first child

Question 19

How should a patient’s medical record indicate he or she has drug allergies?

Answer 19

Outside of the record should be marked

Question 20

What does SOAPP stand for?

Answer 20

subjective, objective, assessment, plan, and prevention

Question 21

Which form should you review to determine the particular duty restrictions of a military worker?

Answer 21

AF Form 469, Duty Limiting Condition Report

Question 22

Workers assigned to hazardous work areas surveyed by BE have this form placed in their medical records

Answer 22

OEHED, Occupational and Environmental Health Exposure Data Form

Question 23

This form is used when one medical section needs the expertise of another medical section

Answer 23

SF 513, Medical Record -Consultation Sheet

Question 24

Review this form for patients either suspected of active tuberculosis or who were exposed to a person with active tuberculosis

Answer 24

SF 519B, Radiologic Consultation Request/Reports

Question 25

A physician who suspects an occupational illness or an occupational injury with chronic health
consequences refers patients to PH for interview with an

Answer 25

SF Form 513

Question 26

Used to record all reference audiograms

Answer 26

DD Form 2215

Question 27

If the employee experiences a significant hearing threshold shift, subsequent 15- and 40-hour audiograms are recorded on this form

Answer 27

DD Form 2216

Question 28

Used to request and record further audiologist evaluation: if the patient requires a detailed follow-up

Answer 28

AF Form 1672

Question 29

Completed for civilian workers’ initial occupational medical examinations

Answer 29

SF Form 78

Question 30

Is completed for military patients’ initial
occupational medical examinations

Answer 30

SF 88, Report of Medical Examination

Question 31

Patients who provide a complete medical history do so on this form

Answer 31

SF 93, Report of Medical History

Question 32

Workers exposed
to ionizing radiation will complete this form

Answer 32

AF Form 1527, History of Occupational Exposure to Ionizing Radiation