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Documentation Assessment

Description

Quiz on Documentation Assessment , created by April Bice on 19/12/2017.
April Bice
Quiz by April Bice , updated more than 1 year ago
April Bice
Created by April Bice over 6 years ago
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Resource summary

Question 1

Question
Infant well flexed, crying intermittently, easily consoled when held is an example of [blank_start]Physical Exam[blank_end]
Image:
Nb Jaundice (binary/octet-stream)
Answer
  • Physical Exam
  • Chief Complaint
  • HPI
  • ROS
  • Assessment
  • Plan

Question 2

Question
Reproducible pain noted on palpation of right sternal-intercostal margin is an example of [blank_start]Physical Exam[blank_end]
Image:
16 Y O Chest Pain (binary/octet-stream)
Answer
  • Physical Exam
  • Chief Complaint
  • HPI
  • ROS
  • Assessment
  • Plan

Question 3

Question
Right typmanic membrane pale-yellow in appearance, bulging with loss of landmarks and light reflex is an example of [blank_start]Physical Exam[blank_end]
Image:
2 Y O Ear Pain (binary/octet-stream)
Answer
  • Physical Exam
  • Chief Complaint
  • HPI
  • ROS
  • Assessment
  • Plan

Question 4

Question
No point tenderness noted over left medial or lateral malleolus is an example of [blank_start]Physical Exam[blank_end]
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • Physical Exam
  • Chief Complaint
  • HPI
  • ROS
  • Assessment
  • Plan

Question 5

Question
Upper respiratory infection is an example of [blank_start]Assessment[blank_end]
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • Assessment
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Plan

Question 6

Question
Jaundice is an example of [blank_start]Assessment[blank_end]
Image:
Nb Jaundice (binary/octet-stream)
Answer
  • Assessment
  • Chief Complaint
  • ROS
  • HPI
  • Physical Exam
  • Plan

Question 7

Question
Costochondritis is an example of [blank_start]Assessment[blank_end]
Image:
16 Y O Chest Pain (binary/octet-stream)
Answer
  • Assessment
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Plan

Question 8

Question
Right Otitis media is an example of [blank_start]Assessment[blank_end]
Image:
2 Y O Ear Pain (binary/octet-stream)
Answer
  • Assessment
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Plan

Question 9

Question
Sprain of Ankle is an example of [blank_start]Assessment[blank_end]
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • Assessment
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Plan

Question 10

Question
Use indirect sunlight exposure (through a window on infant) to help facilitate excretion of bilirubin through stools is an example of [blank_start]Plan[blank_end]
Image:
Nb Jaundice (binary/octet-stream)
Answer
  • Plan
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Assessment

Question 11

Question
Use ibuprofen 400 mg every 6 hours PRN for discomfort is an example of [blank_start]plan[blank_end]
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • Plan
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Assessment

Question 12

Question
Avoid full-weight bearing for the next 5 days by utilizing crutches. May ambulate and advance to full weight bearing as tolerated is an example of [blank_start]Plan[blank_end]
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • Plan
  • Chief Complaint
  • HPI
  • ROS
  • Assessment
  • Physical Exam

Question 13

Question
Amoxicillin (400 mg/5ml), give 5 ml PO BID x 10 days. Dispense Quantity Sufficient (QS) with no refills is an example of [blank_start]Plan[blank_end]
Image:
2 Y O Ear Pain (binary/octet-stream)
Answer
  • Plan
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Assessment

Question 14

Question
Cool mist humidifier at the bedside with sleep is an example of [blank_start]Plan[blank_end]
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • Plan
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Assessment

Question 15

Question
"8 y/o with cough and congestion" is an example of [blank_start]Chief Complaint[blank_end].
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 16

Question
"Cough Started 3 days ago" is an example of [blank_start]HPI[blank_end].
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • HPI
  • Chief Complaint (CC)
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 17

Question
"Newborn with yellow skin” is an example of [blank_start]Chief Complaint (CC)[blank_end]
Answer
  • Chief Complaint (CC)
  • HPI
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 18

Question
"16 y/o with chest pain" is an example of [blank_start]Chief Complaint (CC)[blank_end].
Image:
16 Y O Chest Pain (binary/octet-stream)
Answer
  • Chief Complaint (CC)
  • HPI
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 19

Question
"2 y/o pulling his ears" is an example of [blank_start]Chief Complaint (CC)[blank_end].
Image:
2 Y O Ear Pain (binary/octet-stream)
Answer
  • Chief Complaint (CC)
  • HPI
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 20

Question
"10 y/o with foot pain" is an example of [blank_start]Chief Complaint (CC)[blank_end].
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • Chief Complaint (CC)
  • HPI
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 21

Question
"Yellowness of skin seemed to gradually get worse, not sudden" is an example of [blank_start]HPI[blank_end].
Image:
Nb Jaundice (binary/octet-stream)
Answer
  • HPI
  • Chief Complaint
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 22

Question
"Pain in chest has been worse when moving and better when still" is an example of [blank_start]HPI[blank_end].
Image:
16 Y O Chest Pain (binary/octet-stream)
Answer
  • HPI
  • Chief Complaint
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 23

Question
"Mom says Tylenol has helped the pain in his ears" is an example of [blank_start]HPI[blank_end].
Image:
2 Y O Ear Pain (binary/octet-stream)
Answer
  • HPI
  • Chief Complaint
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 24

Question
"Pain located is in left ankle" is an example of [blank_start]HPI[blank_end].
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • HPI
  • Chief Complaint
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 25

Question
“Was riding his bike and got his left foot 'caught in the wheel spokes'” is an example of [blank_start]HPI[blank_end].
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • HPI
  • Chief Complaint
  • ROS
  • Physical Exam
  • Assessment
  • Plan

Question 26

Question
"Reports a bark-like cough, denies shortness of breath" is an example of [blank_start]ROS[blank_end].
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • ROS
  • Chief Complaint
  • HPI
  • Physical Exam
  • Assessment
  • Plan

Question 27

Question
"Denies Nauseas and Vomiting" is an example of [blank_start]ROS[blank_end].
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • ROS
  • Chief Complaint
  • HPI
  • Physical Exam
  • Assessment
  • Plan

Question 28

Question
"Denies chest palpitations" is an example of [blank_start]ROS[blank_end].
Image:
16 Y O Chest Pain (binary/octet-stream)
Answer
  • ROS
  • Chief Complaint
  • Physical Exam
  • Assessment
  • Plan
  • HPI

Question 29

Question
"Reports limitation of movement in left foot/ankle" is an example of [blank_start]ROS[blank_end].
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • ROS
  • Chief Complaint
  • HPI
  • Physical Exam
  • Assessment
  • Plan

Question 30

Question
"Denies nosebleeds, nasal discharge, and frequency of colds" is an example of [blank_start]ROS[blank_end].
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • ROS
  • Chief Complaint
  • HPI
  • Physical Exam
  • Assessment
  • Plan

Question 31

Question
"Reports change in skin color to yellow, denies rashes" is an example of [blank_start]ROS[blank_end].
Image:
Nb Jaundice (binary/octet-stream)
Answer
  • ROS
  • Chief Complaint
  • HPI
  • Physical Exam
  • Assessment
  • Plan

Question 32

Question
Nasal turbinates erythematous and swollen, clear rhinorrhea present to both nares is an example of [blank_start]Physical Exam[blank_end].
Image:
2 Y O Ear Pain (binary/octet-stream)
Answer
  • Physical Exam
  • Chief Complaint
  • HPI
  • ROS
  • Assessment
  • Plan

Question 33

Question
Not ill-appearing, alert, and smiling is an example of [blank_start]Physical Exam[blank_end].
Image:
8 Y O Cough And Cong (binary/octet-stream)
Answer
  • Physical Exam
  • Chief Complaint
  • HPI
  • ROS
  • Assessment
  • Plan

Question 34

Question
Use the RICE method: Rest, Ice, Compression, and Elevation, for additional comfort and to promote healing is an example of [blank_start]Plan[blank_end]
Image:
10 Y O Foot Pain (binary/octet-stream)
Answer
  • Plan
  • Chief Complaint
  • HPI
  • ROS
  • Physical Exam
  • Assessment
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