MOPS Patient Record Unit Test Review MA (Fall 2014)
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| What is the difference between a medical report and medical record? | A report is a single document. A record is a complete set of information.
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| The determination of a disease is known as the | diagnosis
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| The study of the causes of a disease is known as | etiology
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| The forecasted outcome of a disease is | prognosis
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| A sign is_________ information | objective
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| A symptom is _______ information | subjective
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| SOAP is an acronym for | subjective objective assessment plan
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| What is the proper procedure for correcting an error in a patient's chart? | Draw a line through error, inital and date it
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| List three benefits of shingling | Saves space within the chart. prevents loss of reports, ease for finding information
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| The SOAP approach of writing progress notes is known as the _________ method of record keeping | traditional
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| Whether you shingle or not, how should reports be placed in a patient's chart? | reverse chronological order
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| List three things medical records are used for: | patient education, research, evaluating quality of treatment
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| Know that the patient record is a legal document and always kept confidential |
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| Congenital means | from birth
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| Give one example of a congenital defect | Club feet, Down's Syndrome, born without limbs
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| Should the physician always chart the condition of a patient upon termination of treatment? Is this information subjective or objective | Yes, objective
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| What should be done before any transcribed notes or laboratory reports are placed in a patient's medical record? | Should be reviewed and intialed by physician
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| What does the acronym POMR stand for? | Problem oriented medical record
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| What is percusssion | To tap on the body
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| What is inspection | To observe
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| What is palpation? | To feel
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| What is auscultation | To listen
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| How does the correction of a hadnwritten entry differ from that of a typewritten entry? | No difference
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To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
ma2b
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