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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?

Choose correct answer/s
A

Subjective information only

B

Objective information only

C

Diagnostic information only

D

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:

Choose correct answer/s
A

defer or omit her comments.

B

have her husband call you.

C

quote her concerns verbatim.

D

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?

Choose correct answer/s
A

Relationship to anatomic landmarks

B

Computer graphics

C

Comparison with other patients of same gender and size

D

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:

Choose correct answer/s
A

are methods for recording locations of findings.

B

are used for noting disease progression.

C

are ways for recording laboratory study results.

D

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:

Choose correct answer/s
A

a grading scale of 0 to 4.

B

color and consistency.

C

demographic data and risk factors.

D

associated symptoms in alphabetic order.

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Question 6
Multiple Choice

Drawing of stick figures is most useful to:

Choose correct answer/s
A
compare findings in extremities.
B
demonstrate radiation of pain.
C
indicate consistency of lymph nodes.
D
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?

Choose correct answer/s
A
Common age variations
B
Expected findings
C
Problems needing further evaluation
D
Minor variations
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Question 8
Multiple Choice

A problem may be defined as anything that will require:

Choose correct answer/s
A
evaluation.
B
medication.
C
surgery.
D
treatment.
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Question 9
Multiple Choice

Differential diagnoses belong in the:

Choose correct answer/s
A
history.
B
physical examination.
C
assessment.
D
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?

Choose correct answer/s
A
Diagnostics ordered
B
Therapeutics
C
Patient education
D
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):

Choose correct answer/s
A
progress note.
B
accident report.
C
problem-oriented medical record.
D
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:

Choose correct answer/s
A
history of present illness.
B
differential diagnosis.
C
assessment.
D
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?

Choose correct answer/s
A
Chief complaint
B
History of present illness
C
Past medical history
D
Social history
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Question 14
Multiple Choice

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

Choose correct answer/s
A
problem list.
B
general patient information.
C
social history.
D
history of present illness.
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Question 15
Multiple Choice

The review of systems is a component of the:

Choose correct answer/s
A
physical examination.
B
health history.
C
assessment.
D
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?

Choose correct answer/s
A
History of present illness
B
Past medical history
C
Social history
D
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:

Choose correct answer/s
A
attention span.
B
developmental status.
C
nutritional differences.
D
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?

Choose correct answer/s
A
Fontanel size
B
Liver span
C
Prostate size
D
Thyroid position
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Question 19
Multiple Choice

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

Choose correct answer/s
A
family support systems.
B
previous healthcare visits.
C
over-the-counter medication intake.
D
date of last cancer screening.
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Question 20
Multiple Choice

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

Choose correct answer/s
A
Preventive care
B
Problem oriented
C
Systems review
D
Traditional treatment
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