Chapter 2. Introduction to Health Records
match the abbreviation with its definition: after meals
PC
match the abbreviation with its definition: primary care physician
PCP
match the term with its definition: pupils are equal, round, and reactive to light and accommodation
PERRLA
match the term with its definition: peripherally inserted central catheter
PICC
match the abbreviation with its definition: past medical history
PMHx
match the abbreviation with its definition: by mouth
PO
match the abbreviation with its definition: three times a day
TID
match the abbreviation with its definition: the patient is growing or has grown properly; is well developed and nourished
WDWN
match the abbreviation with its definition: well developed, well nourished
WDWN
match the term with its definition: well developed, well nourished
WDWN
match the term with its definition: the front
antral
Match the part of the medical SOAP note with its description. cause of the problem
assessment
match the term with its definition: to listen
auscultation
Identify the part of the SOAP note in which the following information would be found: initial imaging studies (for example, an x-ray) a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
b. O (objective)
Identify the part of the SOAP note in which the following information would be found: lab results a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
b. O (objective)
Identify the part of the SOAP note in which the following information would be found: the patient's exam a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
b. O (objective)
NOS and NEC are: a. abbreviations used for symptoms and exam findings b. all of these c. none of these d. mean "not otherwise specified" or "not elsewhere classified" e. catchalls for diagnoses that don't quite fit any specific cause
b. all of these
The patient had "tubes placed bilaterally." PMHx Johnny's history is significant for tympanostomy tubes placed bilaterally when he was 2 years old. One tube left a persistent perforation in the tympanic membrane, so he had tympanoplasty at 3 years of age. He has not had any episodes of otitis media in the past 2 years. Which is the correct breakdown and definition of the term bilateral? a. bi (two) + lateral (toward the middle) = in the middle b. bi (two) + lateral (out to the side) = both sides c. bi (side) + lateral (toward the middle) = toward the middle of the side d. bi (side) + lateral (toward the side) = toward the side e. bi (one) + lateral (out to the side) = one side
b. bi (two) + lateral (out to the side) = both sides
indicate which syllable receives emphasis when pronounced: morbidity a. mor b. bid c. i d. ty
b. bid
which health care record is NOT routinely used in a hospital or inpatient health care facility? a. admission summary b. clinic note c. discharge summary d. emergency department note e. progress note
b. clinic note
The following excerpt would most accurately be classified as which kind of health care record? Dear Dr. Childs, Thank you for referring Mr. Samuels to my office. I saw him on March 3, 2015. Mr. Samuels has a 4-month history of increasing pain in his right distal femur. He first noticed pain after being kicked in the leg at a soccer game and was evaluated in your office 3 weeks later for persistent pain. There was a soft tissue mass in his distal femur that was tender to touch. a. prescription b. consult note c. discharge summary d. pathology report e. operative report
b. consult note
which type of health record is sometimes found in the form of a letter? a. clinic note b. consult note c. daily hospital note d. pathology report
b. consult note
indicate which syllable receives emphasis when pronounced: progressive a. pro b. gres c. sive
b. gres
indicate which syllable receives emphasis when pronounced: alert a. a b. lert
b. lert
if a patient is prone, he is: a. standing b. lying down on his belly c. lying down on his right side d. lying down on his left side e. lying down on his back
b. lying down on his belly
indicate which syllable receives emphasis when pronounced: remission a. re b. mis c. sion
b. mis
indicate which syllable receives emphasis when pronounced: genetic a. ge b. net c. ic
b. net
indicate which syllable receives emphasis when pronounced: prognosis a. prog b. no c. sis
b. no
information such as the patient's physical exam, any laboratory findings, and imaging studies performed at the visit would be contained in which part of the diagnostic process? a. assessment b. objective c. plan d.subjective
b. objective
indicate which syllable receives emphasis when pronounced: palpation a. pal b. pa c. tion
b. pa
indicate which syllable receives emphasis when pronounced: impression a. im b. pres c. sion
b. pres
Indicate which syllable receives emphasis when pronounced: coronal a. co b. ro c. nal
b. ro
In the following prescription, which line gives the patient instructions? Amoxicillin 400 mg/5ml Sig. 5 ml PO BID x 10days Dispense 100ml Refills: None Brand name medically necessary a. refills: none b. sig. 5 ml PO BID x 10 days c. dispense 100ml d. brand name medically necessary e. amoxicillin 400mg/5ml
b. sig. 5 ml PO BID x 10 days
indicate which syllable receives emphasis when pronounced: lethargic a. le b. thar c. gic
b. thar
A patient was given a prescription with the following information: "Sig. 5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription? a. the medication will be taken as needed for ten days b. the medication will be taken by mouth twice a day for ten days c. the medication will be taken subcutaneously for ten days d. the medication will be taken by mouth once a day for ten days
b. the medication will be taken by mouth twice a day for ten days
Indicate which syllable receives emphasis when pronounced transverse a. trans b. verse
b. verse
match the term with its definition: both sides
bilateral
Identify the part of the SOAP note in which the following information would be found: a diagnosis a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
c. A (assessment)
Identify the part of the SOAP note in which the following information would be found: list of possible causes that fit the description of the patient's problem a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
c. A (assessment)
The normal blood pressure range is 90/60 to 140/90. A patient's blood pressure has been documented at 120/80. Which of the following abbreviations describes the patient's blood pressure? a. BP WDWN b. BP NAD c. BP WNL d. BP NEC e. BP RRR
c. BP WNL
Match the health record type with its description: documents sent to a primary physician, usually by a specialist, to give an opinion on a more challenging problem
consult note
match the term with its definition: opposite side
contralateral
match the term with its definition: divides the body in slices from front to back
coronal
After a car accident, the medical professional asks the patient questions about her name, location, and the date. The patient is able to accurately answer all of the questions. The patient can be classified as: a. WDWN b. PERRLA c. NAD d. A&O e. ROS
d. A&O
which of the following would NOT describe a patient with a normal physical exam? a. WNL b. NAD, WDWN c. PERRLA, A&O d. CTA, SOB e. CTA, RRR
d. CTA, SOB
the amount of fluids in a patient in and produced is abbreviated: a. H&P b. BMI c. PERRLA d. I/O
d. I/O
Identify the part of the SOAP note in which the following information would be found: scheduling of a surgery a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
d. P (plan)
Identify the part of the SOAP note in which the following information would be found: treatment with medicine a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
d. P (plan)
which of the following pairs of abbreviations are opposites? a. SC, IM b. IM, IV c. NPO, PR d. PO, NPO e. IV, CVL
d. PO, NPO
the A in SOAP stands for a. action b. appraisal c. arrangment d. assessment
d. assessment
which is the correct opposite for the proximal part of the body? a. prone b. ipsilateral c. dorsum d. distal e. ventral
d. distal
which of the following pairs of terms are opposites? a. genetic, hereditary b. acute, abrupt c. exacerbation, symptom d. febrile, afebrile e. lethargic, malaise
d. febrile, afebrile
the risk for being sick is known as: a. mortality b. malignant c. prognosis d. morbidity
d. morbidity
which health record does NOT follow the SOAP format? a. consult note b. daily hospital note c. emergency department d. prescription
d. prescription
PCP refers to the: a. present complaint or problem b. past care provider c. past complaint or problem d. primary care provider e. primary complaint or problem
d. primary care provider
Match the health record type with its description: documents a patient's process during a daily hospital visit
daily hospital note/progress note
match the term with its definition: to be getting worse
degeneration
match the term with its definition: what the health care professional thinks the patient has
diagnosis
match the term with its definition: what the patient has
diagnosis
match the term with its definition: a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
differential diagnosis
match the term with its definition: literally, to unload; to send home
discharge
match the term with its definition: to send home
discharge
Match the health record type with its description: documents a patient's admission and hospital stay (usually a longer stay)
discharge summary
match the term with its definition: what happens to the patient at the end of the visit
disposition
match the term with its definition: the back
dorsal
Which of the following health records describes when and why a patient was admitted to the hospital, documents his/her stay in the hospital, and indicates the type of follow-up the patient will have? a. admission summary b. daily hospital/progress note c. emergency department note d. clinic note e. discharge summary
e. discharge summary
which of the following does NOT refer to "the front"? a. antral b. they refer to "the front" c. ventral d. anterior e. dorsal
e. dorsal
if a patient's infection is classified as occult, it is: a. getting better b. getting worse c. dangerous d. without a known or specific cause e. hidden
e. hidden
Match the term with its definition: the story of the patient's problem
history of present illness
match the term with its definition: no known specific cause; it just happens
idiopathic
match the term with its definition: assessment
impression
match the term with its definition: same side
ipsilateral
match the term with its definition: a decrease in level of consciousness
lethargic
match the term with its definition: not feeling well
malaise
match the term with its definition: dangerous; a problem
malignant
match the term with its definition: something that really stands out
marked
match the term with its definition: the risk for being sick
morbidity
match the term with its definition: the risk for dying
mortality
Match the part of the medical SOAP note with its description. data collected to assist in understanding the nature of the problem
objective
match the term with its definition: keep an eye on
observation
match the term with its definition: to keep an eye on
observation
Match the health record type with its description: documents a surgery
operative report
match the term with its definition: treating the symptoms but not actually getting rid of the cause
palliative
match the term with its definition: to feel
palpation
Match the term with its definition: other significant past illnesses, like gah blood pressure, asthma, or diabetes
past medical history
Match the term with its definition: any past surgeries
past surgical history
match the term with its definition: the organism that causes the problem
pathogen
identify the author of this type of health record: pathology report
pathologist
Match the health record type with its description: documents a pathology procedure
pathology report
match the term with its definition: waiting on
pending
Match the part of the medical SOAP note with its description. treatment with medicine or a procedure
plan
Match the health record type with its description: a medical professional's directions for a patient's medication
prescription
match the abbreviation with its definition: as needed
prn
match the term with its definition: the chances for things getting better or worse
prognosis
match the term with its definition: more and more each day
progressive
match the term with its definition: lying on the belly
prone
match the term with its definition: preventive treatment
prophylaxis
identify the author of this type of health record: radiology report
radiologist
Match the health record type with its description: documents an imaging procedure by a radiologist
radiology report
match the term with its definition: to have again
recurrent
match the term with its definition: most often used to refer to cancer when it gets better; not the same as a cure
remission
match the term with its definition: to get better or improve; most often used when discussing cancer; does not mean cure
remission
Match the term with its definition: any symptoms not directly related to the main problem
review of systems
match the term with its definition: divides the body in slices right to left
sagital
match the term with its definition: a problem resulting from a disease or injury
sequelae
Match the term with its definition: mainly health habits, like smoking, drinking, drug use, or sexual practices
social history
match the term with its definition: extremely clean, germ-free conditions; especially important during medical procedures and surgery
sterile
Match the part of the medical SOAP note with its description. a description of the problem in the patient's own words
subjective
match the term with its definition: lying down on the back
supine
match the term with its definition: to treat the symptoms and make the patient feel better
supportive care
identify the author of this type of health record: operative report
surgeon
match the term with its definition: something the patient feels
symptom
match the term with its definition: divides the body from top to bottom
transverse
match the term with its definition: one side
unilateral
match the abbreviation with its definition: family history
FHx
match the abbreviation with its definition: the patient does not look extremely sick
NAD
match the abbreviation with its definition: catch all for diagnoses that don't quire fit any specific cause
NEC
match the abbreviation with its definition: nothing by mouth
NPO
Match the health record type with its description: documents a patient visit in an office
clinic note
Match the term with its definition: any significant illnesses that run in the patient's family
family history
match the term with its definition: to have a fever
febrile
Match the health record type with its description: documents a patient's admission to the hospital
admission summary
match the term with its definition: to not have a fever
afebrile
Match the term with its definition: the main reason for a visit
chief complaint
match the abbreviation with its definition: before meals
AC
match the abbreviation with its definition: twice daily
BID
match the abbreviation with its definition: measurement of body fat based on height and weight
BMI
match the abbreviation with its definition: chief complaint
CC
match the abbreviation with its definition: the main reason for the visit
CC
match the abbreviation with its definition: description of normal sounding lungs
CTA
match the abbreviation with its definition: emergency room
ER
match the abbreviation with its definition: the amount of fluid a patient has taken in (by IV or mouth) and produced (usually just urine output)
I/O
match the abbreviation with its definition: intravenous
IV
match the abbreviation with its definition: daily
QD
match the abbreviation with its definition: at night
QHS
match the abbreviation with its definition: four times daily
QID
match the abbreviation with its definition: anything else not necessarily directly related to the chief complaint
ROS
match the abbreviation with its definition: respiratory rate
RR
match the abbreviation with its definition: description of a normal heart on an exam
RRR
match the abbreviation with its definition: regular rate and rhythm
RRR
match the abbreviation with its definition: under the skin
SC
Identify the part of the SOAP note in which the following information would be found: information forms provided by the patient prior to the appointment a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
a. S (subjective)
Identify the part of the SOAP note in which the following information would be found: patient's description of the problem or complaint a. S (subjective) b. O (objective) c. A (assessment) d. P (plan)
a. S (subjective)
a patient concern that just started recently, or is a sudden onset, severe symptom, is called: a. acute b. febrile c. lethargic d. chronic e. noncontributory
a. acute
which health record would be used to document a routine pediatric wellness exam? a. clinic note b. consult note c. daily hospital note d. operative report
a. clinic note
Indicate which syllable receives emphasis when pronounced: distal a. dis b. tal
a. dis
Indicate which syllable receives emphasis when pronounced dorsum a. dor b. sum
a. dor
Indicate which syllable receives emphasis when pronounced: dorsal a. dor b. sal
a. dor
an emergency department course: a. explains what transpired during the patient's stay in the emergency department; it includes any diagnostic tests done, the assessment, and a plan for the patient that unfolds over time b. lists the path every patient takes when entering the emergency department treatment c. organizes an emergency department by types of injury d. teaches students how to behave in an emergency department
a. explains what transpired during the patient's stay in the emergency department; it includes any diagnostic tests done, the assessment, and a plan for the patient that unfolds over time
indicate which syllable receives emphasis when pronounced: febrile a. fe b. brile
a. fe
which of the following is an accurate breakdown of the abbreviation IM? a. intramuscular= intra (in, inside) + ar (pertaining to)= inside a muscle b. intermedical = inter (between) + medic/o (medicine) + al (pertaining to) = information shared between medical professionals c. instrumental = the essential portions of a patient's health record d. intramicrobial = intra (in, inside) + micro (small) + bial (pertaining to) = pertaining to the small microorganisms for which a prescription is dedicated
a. intramuscular= intra (in, inside) + ar (pertaining to)= inside a muscle
which of the following is FALSE about the term discharge? a. it can mean that the patient has been cured b. it is included as part of the "plan" section in a health care note c. it refers to a fluid coming out of a part of the body d. it literally means to unload e. it can mean send home
a. it can mean that the patient has been cured
in a problem-based approach, you: a. number the problems, describe how the patient's problem has changed, and provide your plan for what to do about the problem b. focus on what you are doing wrong and who should take over c. try to cause more problems in the patient in the hopes of determining what is really wrong
a. number the problems, describe how the patient's problem has changed, and provide your plan for what to do about the problem
the O in SOAP stands for a. objective b. opinion c. order d. outline
a. objective
indicate which syllable receives emphasis when pronounced: pathogen a. path b. o c. gen
a. path
The following is an excerpt from a consult note. PMHx: CAD with PTCA in 20xx.Hypertension.Hypertriglyceridemia. Medications: Beta blocker, nitroglycerin prn, ASA, antilipidemic agent. Allergies: Penicillin. FHx: Brother deceased from an MI at 69 years of age. SHx: Patient does not smoke. He drinks 1-2 beers per week. Denies illicit drug use. He is married with two grown children and three grandchildren. This information is most accurately classified as: a. patient history b. treatment plan c. review of systems d. past surgical history e. prescription plans
a. patient history
Indicate which syllable receives emphasis when pronounced: plantar a. plan b. tar
a. plan
the P in SOAP stands for a. plan b. procedure c. prognosis d. purpose
a. plan
if a person's head were divided on the coronal plane, which of the following is TRUE: a. the division would be from front to back, and therefore both eyes could be seen on the same plane b. the division would be from left to right, and therefore only one eye would be seen at a time c. the division would be from left to right, and therefore both eyes could be seen on the same plane d. the division would be from front to back, and therefore only one eye would be seen at a time
a. the division would be from front to back, and therefore both eyes could be seen on the same plane
interpret the following abbreviations: "the Pt is 5y/o" a. the patient is 5 years old b. the prescription is 5 years under observation c. the prescription is 5 years old d. none of these
a. the patient is 5 years old
The following is a portion of a patient's consult note: Past Medical History: Noncontributory. Past Surgical History: Balanoplastyfor hypospadias at age 1. Social History: Doug lives with his parents and older sister. He is going into kindergarten in the fall. Family History: Paternal grandfather with polycystic kidney disease. According to the doctor who authored this note, which of the following is true? a. the patient's PMHx is not related to this specific problem b. the patient has never had any surgeries c. the patient is 10 y/o d. the patient has polycystic kidney disease e. there is not enough information to draw any conclusions
a. the patient's PMHx is not related to this specific problem
match the term with its definition: symptoms just started
acute
which of the following is FALSE about the SOAP method? a. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. b. Most medical notes share a consistent pattern in their organization and layout that reflects the SOAP thought process. c. Diagnostic work in medicine is very similar to the investigative work of a detective; thus the SOAP method begins with an analysis and ends with collecting data to confirm the diagnosis. d. The SOAP method is repeated in every health care visit across all disciplines of medicine. e. SOAP reflects a general thought process used by most medical professionals.
c. Diagnostic work in medicine is very similar to the investigative work of a detective; thus the SOAP method begins with an analysis and ends with collecting data to confirm the diagnosis.
which of the following abbreviations would most likely be found in the "plan" portion health record? a. RRR b. PERRLA c. QHS d. Dx e. ROS
c. QHS
a SOAP note is a. a pattern used in writing medical notes b. a way of thinking c. all of these d. none of these
c. all of these
a systemic infection by definition: a. is the organism that cause the problem b. is dangerous problem c. infects all or most of the body d. is a problem resulting from disease or injury e. stays in a certain part of the body
c. infects all or most of the body
which of the following is NOT true about the medical term remission? a. it is most often used when discussing cancer b. it is a term that a medical professional might use in the assessment part of the health record c. it means the illness has been cured d. it means "to get better or improve"
c. it means the illness has been cured
indicate which syllable receives emphasis when pronounced: unremarkable a. un b. re c. mark d. a e. ble
c. mark
A patient has unremarkable symptoms. Unremarkable is a medical term used to mean: a. responsive b. unresponsive c. normal d. it stands out
c. normal
select the health records that document a type of procedure: a. discharge summary b. emergency department note c. operative report d. pathology report e. prescription f. radiology report
c. operative report
Read this excerpt from a patient's health record. PMHx Johnny's history is significant for tympanostomy tubes placed bilaterally when he was 2 years old. One tube left a persistent perforation in the tympanic membrane, so he had tympanoplasty at 3 years of age. He has not had any episodes of otitis media in the past 2 years. This is the patient's: a. chief complaint b. personal social medical history c. past medical history d. history of present illness e. review of systems
c. past medical history
prophylaxis refers to: a. extremely clean, germ free conditions b. treating the symptoms but not actually getting rid of the cause c. preventive treatment d. telling the patient that the problem is not serious or dangerous e. observation of a patient
c. preventive treatment
According to the following discharge summary, which is true about this patient? HPI Mrs. Roxana Collach presented to the ED with a 2-day history of increasing epigastric pain. She described the pain as constant and dull with radiation to her back. She also had progressive anorexia. She denied nausea, emesis, or diarrhea. She was febrile in the ED and had marked epigastric tenderness on exam with guarding. Her abdomen was slightly distended and she was mildly jaundiced. Her elevated amylase and lipase confirmed the suspicion of acute pancreatitis. She was admitted for pain control and IVF. a. she was not given intravenous fluids b. she did not have a fever when she arrived c. she was diagnosed with pancreatitis d. her anorexia was getting better e. she did not have any epigastric tenderness
c. she was diagnosed with pancreatitis
The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the: a. assessment b. objective c. subjective d. plan
c. subjective
the S in SOAP stands for a. scrutinize b. studies c. subjective d. survey
c. subjective
a diagnosis is a. a list of possible causes of the patient's problem or complaint b. ordering of more labs c. the identification of the actual problem d. treatment with medicine or a procedure
c. the identification of the actual problem
Read the following discharge summary: Hospital Course Mrs. Collach was admitted to the medical service. She was placed on NPO status and given IVF and analgesics. An ultrasound revealed gallstones in the common bile duct as the etiology for Mrs. Collach's pancreatitis. Surgery was consulted. On hospital day 2, Mrs. Collach was taken to the OR for laparoscopic choledocholithectomy and cholecystectomy. She tolerated the procedure well. She began a postoperative refeeding plan with a low-protein, low-fat diet. She tolerated advancing the diet, and 2 days after her surgery, her pain had improved enough that she was discharged home. According to this summary, which of the following is true? a. mrs. collach was given palliative care throughout her hospital stay b. mrs. collach spent some time in the intensive care unit c. mrs. collach could eat a low protein, low fat diet when she was first admitted to the hospital d. mrs. collach was given a low protein, low fat diet before her operation e. mrs. collach was not allowed to have anything by mouth and was given intravenous fluids when she was first admitted to the hospital
e. mrs. collach was not allowed to have anything by mouth and was given intravenous fluids when she was first admitted to the hospital
The following excerpt is from which portion of the discharge summary? Labs Admission labs: UA: Pyuria: .20 wbcs; Hematuria: 3 1 blood; Albuminuria: 1 1 protein. Urine culture: E. coli. Blood culture: E. coli. Discharge labs: UA normal. Urine culture normal. Imaging VCUG: No vesicoureteral reflux noted. RUS: No hydronephrosisnoted. Normal. Spiral CT of kidneys on day 3 of admission revealed perinephric abscess formation of the left kidney. a. plan b. subjective c. assessment d. prescription e. objective
e. objective
which of the following health records would NOT include a plan? a. prescription b. consult note c. clinic note d. emergency department note e. pathology report
e. pathology report
The following is an excerpt from a patient's medical record. According to this information, which is NOT true about the patient? T: 98.5; HR: 60; RR: 20; BP: 112/70. General: Pleasant, responsive. No acute distress. HEENT: PERRLA. Mucous membranes moist and pink. Resp: CTA. No wheezes, rales, rhonchi, or crackles. Good air exchange. No increased work of breathing. a. the patient's respiratory rate is 20 b. the patient's heart rate is 60 c. the patient is alert d. the patient is afebrile e. the patient's eyes are not reacting to light
e. the patient's eyes are not reacting to light
a medication prescribed BID is taken: a. before meals b. after meals c. three times a day d. once a day e. twice a day
e. twice a day
Match the health record type with its description: documents a patient's emergency department visit
emergency department note
match the term with its definition: cause
etiology
match the term with its definition: the cause
etiology
match the term with its definition: the symptoms are getting worse
exacerbation
match the abbreviation with its definition: follow up
f/u
