BASIC MEDICAL DOCUMENTATION

Question 1

BASIC MEDICAL DOCUMENTATION (5)

Answer 1

INFO ABOUT PT MEDICAL HISTORY AND PRESENT CONDITION

USED FOR PATIENT AND STAFF EDUCATION AND RESEARCH

USED AS COMMUNICATION TOOL AND LEGAL DOCUMENT

PROVIDES A MAP OR PLAN FOR CONTINUITY OF CARE

SUPPORTING DOCUMENTATION FOR BILLING AND CODING PURPOSES

Question 2

SOAP DOCUMENTATION

Answer 2

SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN

Question 3

SUBJECTIVE (SOAP)

Answer 3

CHIEF COMPLAINT

Question 4

OBJECTIVE(SOAP)

Answer 4

MEASUREABLE DATA - VITALS, LABS, MEASUREMENTS

Question 5

ASSESSMENT (SOAP)

Answer 5

MEDICAL DIAGNOSIS

Question 6

PLAN (SOAP)

Answer 6

FOR TREATMENT

Question 7

PATIENT INTERVIEW

Answer 7

FIRST STEP IN EXAM PROCESS
ESTABLISHES A RELATIONSHIP
EXCHANGE OF INFO

Question 8

reason for appointment

Answer 8

establish - “why are you here today?”
routine checkup, follow up, established pt with symptoms, new patient

Question 9

Chief Complaint

Answer 9

SUBJECTIVE statement made by patient describing most significant symptom
Ask patient questions

Question 10

Vitals

Answer 10

pulse, respirations, blood pressure, pain assessment`

Question 11

oral temp

Answer 11

orally - electronic or digital
98.6

Question 12

Aurally (ear) temp

Answer 12

tympanic
98.6

Question 13

axillary temp

Answer 13

least accurate
under armpit
97.6

Question 14

rectal temp

Answer 14

most accurate
electronic or digital
99.6

Question 15

Pulse

Answer 15

normal 60-100
take at radial for 30 x 3
if irregular take for one minute

Question 16

tachycardia

Answer 16

pulse greater than 100

Question 17

bradycardia

Answer 17

pulse lower than 60

Question 18

pulse - check for

Answer 18

rhythm and volume

Question 19

apical pulse

Answer 19

used for infants using a stethescope

Question 20

apex

Answer 20

5th intercoastal space between ribs on left side and sternum