Quiz
Chapter 05: Documentation
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Questions in this quiz (21)
1During the course of the interview, you should:
- Atake no notes of any kind.
- Btake brief written notes.
- Ctake detailed written notes.
- Drepeat pertinent comments into a Dictaphone.
- Einterrupt the interview to formulate your thoughts.
2Subjective and symptomatic data are:
- Adocumented in your assessment.
- Bnot mentioned in the legal chart.
- Cplaced in the history sections.
- Drecorded with the examination technique.
- Edocumented with the findings.
3The quality of a symptom, such as pain, is subjective information that should be:
- Adeferred until the cause is determined.
- Bdescribed in the history using a 0 to 10 scale.
- Cplaced in the past medical history section.
- Dplaced in the history with objective data.
- Einterpreted in light of your physical findings.
4Drawing of stick figures is most useful to:
- Acompare findings in the extremities.
- Bdemonstrate radiation of pain.
- Cindicate organ enlargement.
- Dindicate mobility of masses.
- Eindicate consistency of lymph nodes.
5Which of the following is an example of a problem requiring recording on the patient’s problem list?
- ACommon age variations
- BExpected findings
- CFindings of unknown origin
- DMinor variations
- EOnly findings that have a clear etiology
6Differential diagnoses belong in the:
- Ahistory.
- Bphysical examination.
- Cassessment.
- Dplan.
- Elaboratory data.
7When recording assessments during the construction of the problem-oriented medical record, the examiner should:
- Acombine all data into one assessment.
- Bcreate an assessment for each problem on the problem list.
- Ccreate an assessment for every abnormal physical finding.
- Dcreate an assessment for every symptom presented in the history.
- Ecreate an assessment for each abnormal laboratory finding.
8Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n):
- Aprogress note.
- Bincident report.
- Cproblem-oriented medical record.
- Dtriage note.
- Enew problem list.
9The effect of the chief concern on the patient’s lifestyle is recorded in which section of the medical record?
- AChief complaint
- BHistory of present illness
- CPast medical history
- DGeneral patient information
- ESocial history
10The patient’s perceived disabilities and functional limitations are recorded in the:
- Aproblem list.
- Bgeneral patient information.
- Csocial history.
- Dreview of systems.
- Epast medical history.
11The review of systems is a component of the:
- Aphysical examination.
- Bhealth history.
- Cassessment.
- Dpast medical and surgical history.
- Epersonal and social history.
12Allergies to drugs and foods are generally listed in which section of the medical record?
- AGeneral patient information
- BPast medical history
- CSocial history
- DProblem list
- EHistory of present illness
13Objective data are usually recorded:
- Aby body systems.
- Bin the history.
- Csubsequent to the assessment and plan.
- Dbefore the health history.
- Ein the problem list.
14Information recorded about an infant differs from that of an adult, mainly because of the infant’s:
- Aattention span.
- Bdevelopmental status.
- Cnutritional differences.
- Dsource of information.
- Elimited past medical history.
15In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?
- AFamily
- BGeneral patient information
- CPersonal and social
- DPresent problem
- EPast medical
16Data relevant to the social history of older adults include information on:
- Afamily support systems.
- Bextra time to assume positions.
- Cover-the-counter medication intake.
- Ddate of last cancer screening.
- Eprevious healthcare visits.
17A SOAP note is used in which type of recording system?
- APreventive care
- BPedigree
- CSystems review
- DTraditional treatment
- EProblem oriented
18The examiner’s evaluation of a patient’s mental status belongs in the:
- Ahistory of present illness.
- Breview of systems.
- Cphysical examination.
- Dpatient education.
- Eproblem list.
19When recording physical findings, which data are recorded first for all systems?
- AReview of systems
- BPercussion
- CPalpation
- DAuscultation
- EInspection
20Regarding another provider’s documented work, it:
- Ais not relevant in a legal proceeding.
- Bwill not affect clinical decisions.
- Cmay be copied verbatim into your documentation
- Dmust be attributed to the source if entered.
- Edoes not affect patient care.
21Which of the following abbreviations is approved by The Joint Commission on Accreditation of Hospitals?
- AU (unit)
- Bqd (daily)
- CMS (morphine sulfate)
- DAll of the above
- ENone of the above
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- Ball: Seidel’s Guide to Physical Examination, 9th Edition Quiz on Chapter 05: Documentation, created by Sugi Williams on 21/01/2020.
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- Sugi Williams
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