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Stack #3873854
| Question | Answer |
|---|---|
| The Blank______ section of a health record tells the patient's story of their health issues. | subjective |
| When describing the directions on the human body, you must use the _______ position | anatomic |
| Which of the following is a specially trained in treating patients respiratory issues under the guidance of a health care provider. | Respiratory Therapist |
| What is the abbreviation for "Electronic Health Record"? | EHR |
| Forming a logical analysis is in the _________ part of the SOAP method. | assessment |
| The main reason for the patient's visit is the | chief complaint |
| Afebrile | To not have a fever |
| Progressive | More and more each day |
| Symptom | Something a patient feels |
| Lethargic | A decrease in level of consciousness |
| Noncontributory | Not related to this specific problem |
| Hereditary | Runs in the family |
| Farther away from the center is | distal |
| Consultation notes are written by the consulting physician and sent to the Blank______. | PCP Primary Care Physician |
| Writes reports for patient care under the supervision of a nurse | MA Medical Assistant |
| Writes reports for radiologic procedures | Radiologist |
| Writes reports for pathology ad laboratory | Pathologist |
| A health care professional who is specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan is called a | Dietician |
| Correct documentation in a patent's chart can prevent which of the following? | Adverse outcomes Potentially fatal outcomes |
| A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health is the | social history |
| Which of the following is the documentation method used for charting in the medical record? | SOAP Subjective blue, Objective red, Assessment yellow, Plan green |
| What type of documentation format is used for consultation notes? | SOAP |
| Pediatrician | A physician who treats children |
| Anesthesiologist | A physician who specializes in pain control and sedation. |
| EMT | Trained in emergency care and transport of the patient. |
| Surgeon | A physician who treats patient surgically. |
| What type of information is recorded on the emergency department note? | Patient assessment Diagnostic tests Plan of care |
| After the medical history is obtained and the physical exam is completed, the attending medical professional writes a detailed | Admission summary |
| Which of the following are acceptable methods of documentation in the patient's chart? | Dictated Handwritten Electronic |
| What factor in the discharge summary is different from the general SOAP documentation method? | The note will lead with the diagnosis. |
| Which of the following physicians document the operative report on the patient? | Surgeon |
| Which of the following are the elements documented in the operative report prepared by the surgeon? | Events that transpired Procedure performed Patient surgical outcome |
| A discharge summary note details Blank______ and Blank______ a patient was admitted. | when; why |
| Which of the following physicians document the operative report on the patient? | surgeon |
| What is the name of the report documented by the health care provider who assesses the patient's care each day? | Daily Report Progress Note |
| Most patients seen by the medical staff in an emergency department are what type of patients? | new |
| Which of the following is mentioned in a pathology report? | What was seen in detail Reason for the study Pathologist's assessment |
| The assessment is also known as a(n) | differential diagnosis. |
| Which of the following are documented in the discharge summary of a patient? | How patient felt when admitted What types of follow-up are required What happened during patient's stay at the hospital |
| Which of the following abbreviations means "intensive care unit"? | ICU |
| Which of the following report explains the reason for ordering a radiologic image. | radiology |
| How often are progress notes documented in the patient's chart? | daily |
| How often are progress notes documented in the patient's chart? | (B) |
| (R) | Right |
| VS | Vital Signs |
| L | left |
| The pathology report is very similar to which type of report? | Radiology report |
| The second line of the prescription, which provides the patient's instructions, is the | sig. |
| Which of the following abbreviations means "after surgery"? | post-op |
| Which of the following are documented on the radiology report? | Reason image was ordered How image was performed Radiologist assessment |
| Which of the following is mentioned in a pathology report? | What was seen in detail Reason for the study Pathologist's assessment |
| The third line of the prescription, which tells the pharmacist how much medication to give the patient, is called | dispense |
| The prescription form is documented in the ____________ part of the SOAP method. | plan |
| BID | Twice daily |
| TID | Three time a day |
| QHS | At night |
| QD | Daily |
| QID | four times daily |
| Which abbreviation means "after meals"? | PC |
Created by:
j.jgarmon05