Quiz 3 and 5

Question 1

7 cardinal aspects of HPI include…

Answer 1

Location
Onset
Pain description/ severity
Alleviating/aggravating factors
Radiation
Temporal pattern
Symptoms

Question 1

List several pertinent aspects of PMH

Answer 1

Medications/ drugs/ vitamins and supplements
Allergies
Past surgeries/ hospitalizations
Health maintenance/ immunizations

Question 2

List several pertinent aspects of SH

Answer 2

Drug or alcohol use
Lifestyle- diet and exercise
Career and personal interests
Home life/ stressors

Question 3

List 5 factors of the subjective paragraph in order

Answer 3

1- onset
2- severity
3- aggravating factors
4- pertinent positives
5- pertinent negatives

Question 4

List aspects of the objective paragraph in order (oropharynx, abdomen, lungs, neck, skin)

Answer 4

1- skin
2-oropharynx
3- neck
4- lungs
5- abdomen

Question 5

List the order of 7 aspects that should be included in the plan

Answer 5

1- diagnostics
2- referrals
3- treatments
4- discuss DDx with pt
5- pt education
6- follow up appointment
7- contact/ when to go to the ED

Question 6

history from spouse, FH, ROS, meds, and onset of CC are examples of _________ information

Answer 6

subjective

Question 7

List 6 components of subjective information

Answer 7

1- CC
2-HPI
3- PMH
4- FH
5- SH
6- ROS

Question 8

List 4 components of objective information

Answer 8

1- vital signs
2- general assessment
3- PE
4- Test results

Question 9

list PE order

Answer 9

skin
EENT
neck
chest
abdomen
GU
extremities
MSK
neuro

Question 10

BMP

Answer 10

basal metabolic panel

Question 11

Hct

Answer 11

hematocrit

Question 12

Hgb

Answer 12

hemoglobin

Question 13

MRI

Answer 13

magnetic resonance imaging

Question 14

SOAP

Answer 14

subjective, objective, assessment, plan

Question 15

WNL

Answer 15

within normal limits

Question 16

AD CAVA DIMPLS

Answer 16

A- admit
D- diagnoses
C-condition
A-activity
V- vital signs
A- allergies
D-diet
I- interventions
M- medications
P- procedures
L- labs
S- special instructions

Question 17

ADEs

Answer 17

adverse drug events

Question 18

CAD

Answer 18

coronary artery disease

Question 19

CPOE

Answer 19

computerized provider order entry

Question 20

CVA

Answer 20

cerebrovascular accident

Question 21

D5NS

Answer 21

5% dextrose in normal saline

Question 22

H & H

Answer 22

hematocrit and hemoglobin

Question 23

ISMP

Answer 23

Institute for safe medication practice

Question 24

NPSG

Answer 24

national patient safety goal

Question 25

OCR

Answer 25

office of civil rights

Question 26

PACU

Answer 26

postanesthesia care unit

Question 27

RLL

Answer 27

right lower lobe

Question 28

S/P

Answer 28

status post

Question 29

AMI

Answer 29

acute myocardial infarction

Question 30

BRP

Answer 30

bed rest with bathroom priveleges

Question 31

CDSS

Answer 31

clinical decision support system

Question 32

COPD

Answer 32

chronic obstructive pulmonary disease

Question 33

CT

Answer 33

computed tomography

Question 34

CXR

Answer 34

chest x-ray

Question 35

ECG

Answer 35

electrocardiogram

Question 36

E/M

Answer 36

evaluation/ management

Question 37

IT

Answer 37

information technology

Question 38

NS

Answer 38

normal saline

Question 39

OOB

Answer 39

out of bed

Question 40

PCA

Answer 40

patient controlled analgesia

Question 41

SVN

Answer 41

single volume nebulizer

Question 42

HD

Answer 42

hospital day

Question 43

JVD

Answer 43

jugular venous distension

Question 44

EBL

Answer 44

estimated blood loss

Question 45

POD

Answer 45

post-operative day

Question 46

AMA

Answer 46

against medical advise

Question 47

CEA

Answer 47

carcinoembryonic antigen

Question 48

list several questions that should be answered daily for post-op patients

Answer 48

Are they getting adequate pain relief? Has bowel function returned? Can activity or diet be advanced? Can sutures, drains, or tubes be removed?

Question 49

List 7 components of a procedure note

Answer 49

1- name of procedure 2- indication for procedure 3- consent 4- anesthesia 5- details of procedure 6- findings 7- complications

Question 50

5 components of operative note

Answer 50

1-date/ name of procedure 2- indication for procedure 3- surgeon and assistants 4- post-op diagnoses 5- complications

Question 51

3 risks associated with copying and pasting notes

Answer 51

1- inaccurate or outdated info 2- inconsistencies 3- unnecessarily long notes

Question 52

5 Ws of post-op fevers

Answer 52

Wind (resp) Wound (skin) Water (urinary) Walk (vascular) Wonder drug (multi system)

Question 53

list 3 clinical RFs for readmission

Answer 53

steroids/ narcotics CHF Diabetes or cancer

Question 54

list 4 non-clinical RFs for readmission

Answer 54

premature discharge lack of support system homelessness or substance abuse

Question 55

list at least 3 components of discharge orders

Answer 55

disposition activity diet (also medications, follow up, notification)

Question 56

3 components of activity with discharge include...

Answer 56

lifting weight limit driving status wound care (swimming, showering)

Question 57

7 components of discharge summary include...

Answer 57

1- date of admission 2- admitting and discharge Dx 3- attending physician, PCP, consults 4- procedures 5- brief history 6- hospital course 7- disposition 8- discharge medication, instructions, follow up

Question 58

list 3 people who could see a discharge summary

Answer 58

1- healthcare team 2- insurance carriers 3- quality assurance personnel

Question 59

3 diagnoses for pts most likely to leave AMA

Answer 59

smokers substance abuse mental illness

Question 60

list 3 things that should be included in an AMA note

Answer 60

name and relationship to pt of witnesses direct quotes of why pt wants to leave document discharge instructions and follow-up care like normal