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Question 1

Free

Multiple Choice

Which part of the information contained in the patient's record may be used in court?

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Subjective information only

Objective information only

Diagnostic information only

All information

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Question 2

Free

Multiple Choice

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S's loss of appetite, it would be better to:

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defer or omit her comments.

have her husband call you.

quote her concerns verbatim.

refer her for psychiatric treatment.

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Question 3

Free

Multiple Choice

Which is an effective adjunct to document the location of findings during the recording of the physical examination?

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Relationship to anatomic landmarks

Computer graphics

Comparison with other patients of same gender and size

Comparison to previous examinations using light pen markings

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Question 4

Free

Multiple Choice

The position on a clock, topographic notations, and anatomic landmarks:

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are methods for recording locations of findings.

are used for noting disease progression.

are ways for recording laboratory study results.

should not be used in the legal record.

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Question 5

Free

Multiple Choice

Regardless of the origin, discharge is described by noting:

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a grading scale of 0 to 4.

color and consistency.

demographic data and risk factors.

associated symptoms in alphabetic order.

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Question 6

Multiple Choice

Drawing of stick figures is most useful to:

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compare findings in extremities.

demonstrate radiation of pain.

indicate consistency of lymph nodes.

indicate mobility of masses.

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Question 7

Multiple Choice

Which is an example of a problem that requires recording on the patient's problem list?

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Common age variations

Expected findings

Problems needing further evaluation

Minor variations

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Question 8

Multiple Choice

A problem may be defined as anything that will require:

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evaluation.

medication.

surgery.

treatment.

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Question 9

Multiple Choice

Differential diagnoses belong in the:

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history.

physical examination.

assessment.

plan.

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Question 10

Multiple Choice

Which of the following is not a component of the plan portion of the problem-oriented medical record?

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Diagnostics ordered

Therapeutics

Patient education

Differential diagnosis

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Question 11

Multiple Choice

Your 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):

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progress note.

accident report.

problem-oriented medical record.

triage note.

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Question 12

Multiple Choice

A detailed description of the symptoms related to the chief complaint is presented in the:

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history of present illness.

differential diagnosis.

assessment.

general patient information section.

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Question 13

Multiple Choice

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record?

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Chief complaint

History of present illness

Past medical history

Social history

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Question 14

Multiple Choice

The patient's perceived disabilities and functional limitations are recorded in the:

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problem list.

general patient information.

social history.

history of present illness.

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Question 15

Multiple Choice

The review of systems is a component of the:

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physical examination.

health history.

assessment.

past medical-surgical history.

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Question 16

Multiple Choice

Allergies to drugs and foods are generally listed in which section of the medical record?

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History of present illness

Past medical history

Social history

Problem list

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Question 17

Multiple Choice

Information recorded about an infant differs from that recorded about an adult, mainly because of the infant's:

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attention span.

developmental status.

nutritional differences.

source of information.

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Question 18

Multiple Choice

Which finding is unique to the documentation of a physical examination of an infant?

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Fontanel size

Liver span

Prostate size

Thyroid position

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Question 19

Multiple Choice

Data relevant to the social history of older adults includes information on:

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family support systems.

previous healthcare visits.

over-the-counter medication intake.

date of last cancer screening.

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Question 20

Multiple Choice

A SOAP note is used in which type of recording system?

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Preventive care

Problem oriented

Systems review

Traditional treatment

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