Intoduction To Health Records

Question 1

Forming a logical analysis is in the _________ part of the SOAP method.

Answer 1

Assessment

Question 2

What would be included in the subjective section of a health record?

Answer 2

Current medication’s; timing of the problem; reason for the visit

Question 3

Correct documentation and a patient’s chart can prevent which of the following?

Answer 3

Adverse outcomes; potentially fatal outcomes

Question 4

A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health is the …

Answer 4

Social history

Question 5

Data compiled through laboratory findings is considered…

Answer 5

Objective

Question 6

What are acceptable methods of documentation in a patient’s chart?

Answer 6

Dictated, electronic, handwritten

Question 7

The _______ section of a health record tells the patients story of their health issues.

Answer 7

Subjective

Question 8

What type of documentation format is used for consultation notes?

Answer 8

SOAP

Question 9

Who are specially trained in, treating patients respiratory issues under the guidance of a healthcare provider?

Answer 9

Respiratory therapist

Question 10

Most patients seen by the medical staff in an emergency department are what type of patients?

Answer 10

New

Question 11

Subjective

Answer 11

Blue

Question 12

Objective

Answer 12

Red

Question 13

Assessment

Answer 13

Yellow

Question 14

Plan

Answer 14

Green

Question 15

Afebrile

Answer 15

To not have a fever

Question 16

Progressive

Answer 16

More and more each day

Question 17

Symptom

Answer 17

Something a patient feels

Question 18

Lethargic

Answer 18

A decrease in level of consciousness

Question 19

After the medical history, history is obtained the physical exam is completed, the attending medical professional rights a detailed…

Answer 19

Admission summary

Question 20

Consultation notes are written by the consulting physician, and sent to the…

Answer 20

PCP

Question 21

What is documented in the discharge summary of a patient?

Answer 21

What types of follow up are required; how patient felt when admitted; what happened during patient’s stay at the hospital

Question 22

What type of information is recorded on the emergency department note?

Answer 22

Plan of care; patient assessment; diagnostic tests

Question 23

Which physicians document the operative report on the patient?

Answer 23

Surgeon

Question 24

The main reason for the patient visit is the…

Answer 24

Chief complaint

Question 25

What is the name of the report documented by the healthcare provider who assesses the patient’s care each day?

Answer 25

Progress note; daily report

Question 26

What type of report explains the reason for ordering a radiologic image?

Answer 26

Radiology

Question 27

The assessment is also known as a(an)…

Answer 27

Differential diagnosis

Question 28

A discharge summary note details ______ and _______ a patient is admitted.

Answer 28

When; why

Question 29

A pathology report is very similar to which type of report?

Answer 29

Radiology report

Question 30

Name the report documented after a surgery was performed by a surgeon

Answer 30

Operative report

Question 31

What documentation is a focus on the daily report/progress note

Answer 31

Subjective part

Question 32

What is documented on the radiology report?

Answer 32

How image was performed; reason image was ordered; radiologist assessment

Question 33

The prescription form is documented in the _______ part of the SOAP method

Answer 33

Plan

Question 34

What parts of the SOAP method or heavily used to document and admission summary?

Answer 34

Objective; subjective

Question 35

What is mentioned in a pathology report?

Answer 35

What was seen in detail; reason for the study; pathologist’s assessment

Question 36

Abbreviation for bilateral

Answer 36

(B)

Question 37

Which physicians documents the operative report on the patient?

Answer 37

Surgeon 

Question 38

What abbreviation means after meals?

Answer 38

PC

Question 39

How often are progress notes documented in the patient’s chart?

Answer 39

Daily

Question 40

The second line of the prescription, which provides the patient’s instructions, is the…

Answer 40

Sig.

Question 41

What abbreviation means daily?

Answer 41

QD

Question 42

The prescription form is documented in the __________ part of the SOAP method.

Answer 42

Plan

Question 43

Subjective

Answer 43

A description of the problem in the patients own words

Question 44

Plan

Answer 44

Treatment with medicine or a procedure

Question 45

Objective

Answer 45

Data collected to assist in understanding the nature of the problem

Question 46

Assessment

Answer 46

Cause of the problem

Question 47

Medical professionals directions for a patient’s medication

Answer 47

Prescription

Question 48

Documents a patient’s emergency department visit

Answer 48

Emergency department note

Question 49

Documents a patient’s progress during a daily hospital visit

Answer 49

Daily hospital note/progress note

Question 50

Documents and imaging procedure by a radiologist

Answer 50

Radiology report

Question 51

Documents a pathology procedure

Answer 51

Pathology report

Question 52

Documents a patient’s admission to the hospital

Answer 52

Admission summary

Question 53

Documents a surgery

Answer 53

Operative report

Question 54

Documents a patient’s visit in an office setting

Answer 54

Clinic note

Question 55

Documents sent to a primary position, usually specialist, to give an opinion on the more challenging problem

Answer 55

Consult note

Question 56

Documents a patient’s admission and hospital stay (usually a longer stay)

Answer 56

Discharge summary

Question 57

Any past surgeries

Answer 57

Past surgical history

Question 58

Mainly health habits, like smoking, drinking, drug use, or sexual practices

Answer 58

Social history

Question 59

The story of the patient’s problem

Answer 59

History of present illness

Question 60

Any significant illness that runs in the patient’s family

Answer 60

Family history

Question 61

Other significant past illnesses, like high blood pressure, asthma, or diabetes

Answer 61

Past medical history

Question 62

The main reason for a visit

Answer 62

Chief complaint

Question 63

Any symptoms not directly related to the main problem

Answer 63

Review of systems