Question 1

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

Accepted Answer

A)   Chief complaint
B)   History of present illness
C)   Past medical history
D)   Social historyE) B) and C)
F) C) and D)

Question 2

Eye examination of the newborn does not routinely include assessment of:

Accepted Answer

A)   the red reflex.
B)   the corneal reflex.
C)   object tracking.
D)   the fundus.E) A) and C)
F) B) and C)

Question 3

When recording assessments during the construction of the problem-oriented medical record, the examiner should:

Accepted Answer

A)   combine all data into one assessment.
B)   create an assessment for each problem on the problem list.
C)   create an assessment for every abnormal physical finding.
D)   create an assessment for every symptom presented in the history.E) None of the above
F) A) and C)

Question 4

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

Accepted Answer

A)   Common age variations
B)   Expected findings
C)   Problems needing further evaluation
D)   Minor variationsE) C) and D)
F) None of the above

Question 5

Differential diagnoses belong in the:

Accepted Answer

A)   history.
B)   physical examination.
C)   assessment.
D)   plan.E) A) and C)
F) B) and C)

Question 6

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

Accepted Answer

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.E) B) and D)
F) None of the above

Question 7

Drawing of stick figures is most useful to:

Accepted Answer

A)   compare findings in extremities.
B)   demonstrate radiation of pain.
C)   indicate consistency of lymph nodes.
D)   indicate mobility of masses.E) A) and B)
F) None of the above

Question 8

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n) :

Accepted Answer

A)   progress note.
B)   accident report.
C)   problem-oriented medical record.
D)   triage note.E) All of the above
F) B) and C)

Question 9

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

Accepted Answer

A)   Fontanel size
B)   Liver span
C)   Prostate size
D)   Thyroid positionE) B) and D)
F) B) and C)

Question 10

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:

Accepted Answer

A)   defer or omit her comments.
B)   have her husband call you.
C)   quote her concerns verbatim.
D)   refer her for psychiatric treatment.E) A) and B)
F) None of the above

Question 11

The quality of a symptom, such as pain, is subjective information that should be:

Accepted Answer

A)   deferred until the cause is determined.
B)   described in the history.
C)   placed in the past medical history section.
D)   placed in the history with objective data.E) C) and D)
F) B) and C)

Question 12

During the course of the interview, you should:

Accepted Answer

A)   take no notes of any kind.
B)   take brief written notes.
C)   take detailed written notes.
D)   repeat pertinent comments into a dictation devise.E) A) and B)
F) A) and C)

Question 13

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of this information is part of Ms. G's _____ history.

Accepted Answer

A)   family
B)   past medical
C)   personal and social
D)   present problemE) A) and B)
F) A) and C)

Exam 26: Recording Information

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

Correct Answer
verified

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

Correct Answer
verified

Drawing of stick figures is most useful to:

Correct Answer
verified

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n) :

Correct Answer
verified

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

Correct Answer
verified

During the course of the interview, you should:

Correct Answer
verified

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

Correct Answer
verified

Eye examination of the newborn does not routinely include assessment of:

Correct Answer
verified

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:

Correct Answer
verified

When recording assessments during the construction of the problem-oriented medical record, the examiner should:

Correct Answer
verified

Differential diagnoses belong in the:

Correct Answer
verified

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of this information is part of Ms. G's _____ history.

Correct Answer
verified

The quality of a symptom, such as pain, is subjective information that should be:

Correct Answer
verified

Exam 26: Recording Information

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Drawing of stick figures is most useful to:

Correct AnswerverifiedShow Answer

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n) :

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

During the course of the interview, you should:

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Eye examination of the newborn does not routinely include assessment of:

Correct AnswerverifiedShow Answer

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:

Correct AnswerverifiedShow Answer

When recording assessments during the construction of the problem-oriented medical record, the examiner should:

Correct AnswerverifiedShow Answer

Differential diagnoses belong in the:

Correct AnswerverifiedShow Answer

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of this information is part of Ms. G's _____ history.

Correct AnswerverifiedShow Answer

The quality of a symptom, such as pain, is subjective information that should be:

Correct AnswerverifiedShow Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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