Chapter 5: Documentation Flashcards
During the course of the interview, you should: a. take no notes of any kind. b. take brief written notes. c. take detailed written notes. d. repeat pertinent comments into a Dictaphone. e. interrupt the interview to formulate your thoughts.
ANS: B During the interviewing process, it is important to maintain eye contact with the patient and to spend as little time as possible looking at your notes, so brief written notes are more practical. Later you can go back and formulate a well-versed history by linking all the pieces together.
Subjective and symptomatic data are: a. documented in your assessment. b. not mentioned in the legal chart. c. placed in the history sections. d. recorded with the examination technique. e. documented with the findings.
ANS: C Subjective data, as well as symptomatic data, should not be part of the physical examination findings; rather, their documentation is appropriate for the history portion.
The quality of a symptom, such as pain, is subjective information that should be: a. deferred until the cause is determined. b. described in the history using a 0 to 10 scale. c. placed in the past medical history section. d. placed in the history with objective data. e. interpreted in light of your physical findings.
ANS: B Pain is subjective, and only the patient can rate the perceived severity. Pain, therefore, should be recorded in the history using a 0 to 10 scale.
Drawing of stick figures is most useful to: a. compare findings in the extremities. b. demonstrate radiation of pain. c. indicate organ enlargement. d. indicate mobility of masses. e. indicate consistency of lymph nodes.
ANS: A Simple drawings, such as stick figures, are more practical illustrations for findings in the extremities. Radiation of pain, organ enlargement, consistency of lymph nodes, and mobility of masses would not be adequately described by such simple drawings.
Which of the following is an example of a problem requiring recording on the patient’s problem list? a. Common age variations b. Expected findings c. Findings of unknown origin d. Minor variations e. Only findings that have a clear etiology
ANS: C Any problem is worth noting on the patient problem list even if the etiology or significance is unknown. Common age variations, expected findings, and minor variations within normal limits should not be classified as problems.
Differential diagnoses belong in the: a. history. b. physical examination. c. assessment. d. plan. e. laboratory data.
ANS: C Differential diagnoses for problems that have not been diagnosed are placed in the assessment category for each problem. The differentials are prioritized, and contributing factors are identified.
When recording assessments during the construction of the problem-oriented medical record, the examiner should: 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. create an assessment for each abnormal laboratory finding.
ANS: B After the examiner has a list of problems constructed, an assessment is made for each unique problem.
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): a. progress note. b. incident report. c. problem-oriented medical record. d. triage note. e. new problem list.
ANS: A A second visit with the clinician is always recorded on a progress note, noting any updates to the condition.
The effect of the chief concern on the patient’s lifestyle is recorded in which section of the medical record? a. Chief complaint b. History of present illness c. Past medical history d. General patient information e. Social history
ANS: B The effect of the patient’s complaint on his or her current everyday lifestyle or work performance is recorded in the history of present illness.
The patient’s perceived disabilities and functional limitations are recorded in the: a. problem list. b. general patient information. c. social history. d. review of systems. e. past medical history.
ANS: E Past medical history contains information about the patient’s lifetime as well as disabilities or functional limitations that alter activities of daily living. TOP: Discipline: Behavioral
The review of systems is a component of the: a. physical examination. b. health history. c. assessment. d. past medical and surgical history. e. personal and social history.
ANS: E Review of systems relates health history according to physical systems and is related just before the actual physical examination.
Allergies to drugs and foods are generally listed in which section of the medical record? a. General patient information b. Past medical history c. Social history d. Problem list e. History of present illness
ANS: B The past medical history section contains information such as drugs, foods, and environmental allergies.
Objective data are usually recorded: a. by body systems. b. in the history. c. subsequent to the assessment and plan. d. before the health history. e. in the problem list.
ANS: A All objective data are recorded by body systems and anatomic locations.
Information recorded about an infant differs from that of an adult, mainly because of the infant’s: a. attention span. b. developmental status. c. nutritional differences. d. source of information. e. limited past medical history.
ANS: B The organizational structure of an infant’s record is different because the infant’s current and future health is referenced in terms of developmental status.
In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data? a. Family b. General patient information c. Personal and social d. Present problem e. Past medical
ANS: D For a newborn, the focus of recorded information is the details of the mother’s pregnancy, the gestational development, and events occurring since birth. These data are recorded in the present problem section of the history.
Data relevant to the social history of older adults include information on: a. family support systems. b. extra time to assume positions. c. over-the-counter medication intake. d. date of last cancer screening. e. previous healthcare visits.
ANS: A The social history of older adults includes community and family support systems. Healthcare visits, medications, cancer screenings, and extra time to assume positions for the physical examination are not part of the social history.
A SOAP note is used in which type of recording system? a. Preventive care b. Pedigree c. Systems review d. Traditional treatment e. Problem oriented
ANS: E A SOAP note, which includes subjective problem data, objective problem data, assessment, and plan, is a type of recording system that has a problem-oriented style.
The examiner’s evaluation of a patient’s mental status belongs in the: a. history of present illness. b. review of systems. c. physical examination. d. patient education. e. problem list.
ANS: C Mental status assessment, including cognitive and emotional stability and speech and language, is part of the physical examination. Anything subjective is part of the review of systems and those findings that are objective are part of the provider’s assessment.
When recording physical findings, which data are recorded first for all systems? a. Review of systems b. Percussion c. Palpation d. Auscultation e. Inspection
ANS: E Physical assessment for all systems begins with inspection.
Regarding another provider’s documented work, it: a. is not relevant in a legal proceeding. b. will not affect clinical decisions. c. may be copied verbatim into your documentation. d. must be attributed to the source if entered. e. does not affect patient care.
ANS: D It is unacceptable to copy other providers’ documented work (e.g., history taken, examination performed, or thought processes outlined) and enter it into your own documentation as if you did the work. Text copied from another person’s note must always be attributed to the source. This is not only an important concept in a legal proceeding, but it is also critical for safe patient care.
Which of the following abbreviations is approved by The Joint Commission on Accreditation of Hospitals? a. U (unit) b. qd (daily) c. MS (morphine sulfate) d. All of the above e. None of the above
ANS: B The Joint Commission has identified “improving communications among caregivers” as a patient safety goal. Certain abbreviations have been placed on a “do not use” list when an error in misreading the abbreviation could cause harm. All of the above abbreviations are on the “do not use” list.
Which part of the information contained in the patient’s record may be used in court? a. Subjective information only b. Objective information only c. Diagnostic information only d. All information
ANS: D Anything that is entered into a patient’s record, in paper or electronic form, is a legal document and can be used in court.
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: a. defer or omit her comments. b. have her husband call you. c. quote her concerns verbatim. d. refer her for psychiatric treatment.
ANS: C It is best to document what you observe and what is said by the patient rather than documenting your interpretation. Listening and quoting exactly what the patient says is the better rule to follow.
Which is an effective adjunct to document the location of findings during the recording of the physical examination? 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
ANS: A Abnormal or normal findings are best described in relationship to universal topographic and anatomic landmarks.
