Clinicals: Chapter 22

Question 1

the __ is the main reason the patient has come to the doctor

Answer 1

chief complaint

Question 2

Mary O’Keefe calls Inner City Health Care to schedule an emergency appointment & tells Ellen Armstrong, CMAS (AMT), that her 3yr old son Chris awakened during the night with extreme pain in his right ear. This is a __ complaint, as it is known by the patient but cannot be seen or measured by the provider

Answer 2

Subjective

Question 3

Dr. king examines 3yr old Chris’ right ear with an otoscope & observes that the ear is inflamed and draining. Since these conditions can be visualized, they are called __ signs

Answer 3

Objective

Question 4

Dr. Lewis confirms a __ of acute appendicitis for a female emergency patient based on subjective and objective information from the patient’s history, the findings of the physical examination, & the results of the laboratory tests ordered

Answer 4

Clinical diagnosis

Question 5

__ is a traditional form of charting that consists of a chronological set of notes for each visit, beginning with the patient’s first visit

Answer 5

SOMR

Question 6

__ charting is the charting method that lists patient data in the following order: subjective, objective, assessment, & plan

Answer 6

SOAP

Question 7

Squired abnormal immune responses to substances (allergens) that do not normally cause reactions are called __

Answer 7

Allergies

Question 8

The most efficient way of record chart notes, especially in multi provider clinics or practices is __

Answer 8

POMR

Question 9

__ is another more comprehensive approach to charting, which encourages greater detail than in SOAP/SOAPER

Answer 9

CHEDDAR