Chapter 21 Review
Give a minimum of four rules that must be followed when documenting in a patient's paper record.
Make all corrections as legally prescribed, use black ink, note allergies in red ink, do not skip any lines, do not leave any blank spaces, and use correct medical terminology, correct spelling, and concise form.
Define open-ended and closed questions and statements and provide an example of each.
Open-ended questions ask for general information, such as, "Tell me how you are feeling today." Closed questions ask for specific information, such as "Have you been immunized against hepatitis B?"
Identify the legal and ethical issues associated with the medical record.
Patient confidentially and proper documentation in the chart must be maintained, and HIPAA guidelines must be followed at all times, because the medical record is a legal document.
Describe the organization of SOAPE notes.
SOAPE notes are organized as follows: S is for subjective data, which include the purpose of the visit, with the patient's words in quotation marks, or a summary of the patient's statement about the chief complaint. O is for objective data, which include anything observed or measurable, including vital signs (VS), the exact anatomic location of an injury, difficulty with gait, and so on. Objective data can be repeatedly measured, which means that regardless of how many different healthcare workers observe the patient or document the sign, the same or very similar numbers or explanations would be given. A is for assessment of the problem, which is usually the physician's preliminary diagnosis or the cause of the patient's chief complaint. P is for the plan of care, which is the physician's documentation regarding how the health problem will be managed, including diagnostic studies, treatments, and patient education. E is for evaluation, which is the assessment of the patient's understanding of the treatment or the ability to comply with the treatment plan. It may also be used to document a follow-up on medication or treatments administered in the physician's office.
Describe the four sections of the POMR.
The POMR system includes four basic parts: 1. Database: This includes the patient's health history, the physical examination findings, and the results of baseline laboratory and diagnostic procedures. This information allows the physician to compile a health problem list for the patient. 2. Problem list: This is a list of the identified problems kept in the front of the patient's chart. It is the table of contents or the index of the chart that defines the patient's health concerns, including diagnoses, treatment, and educational needs. The problem list takes a holistic approach by including psychosocial and physical needs. Each problem entered is numerically listed and dated and is supported by the database. The problems are then identified and referenced throughout progress note documentation by their assigned number. If over time an additional problem is identified, the information is added to the problem list. If the problem is resolved, the date of problem resolution is entered next to the problem. 3. Plan: This is a written plan for each problem identified on the problem list; it outlines further studies, treatments, and patient education. 4. Progress notes
What is the best way to obtain specific information about a patient when taking the medical history? A. Summarize the facts revealed by the patient when answering questions. B. Ask direct questions that can be answered briefly. C. Restate what the patient has said to check the accuracy of what was heard. D. Encourage the patient to explain the answers fully.
B. Ask direct questions that can be answered briefly.
Which of the following involves asking a question or summarizing a patient's thoughts? A. Restatement B. Clarification C. Reflection
B. Clarification
Developing patient __________ means the medical assistant has developed a positive relationship with the patient.
0. rapport
The grandmother of a young patient reports that the child has had a temperature of 101.6° for 2 days. This information would be documented in the __________ part of a SOAPE chart note.
0. subjective
The physician's initial impression of what is wrong with the patient is called the __________ diagnosis.
0. working
The physician's initial impression of the patient's presenting problem is called the __________.
0. working diagnosis
__________ care considers the patient as a whole including the physical, emotional, social, economic, and spiritual needs of the person.
1. Holistic
When you begin working in the healthcare environment, it will be important that you follow HIPAA regulations about patient confidentiality. Summarize four important factors to consider when complying with HIPAA.
1. Limit the disclosure of PHI according to the patient's request. 2. Do not release restricted information. 3. The patient has the right to request that confidential information be sent in a manner that the patient decides is best. This information must be documented and followed each time the office attempts to contact the patient. 4. The facility owns the patient's record, but the patient owns the information included in the record. 5. Secure all medical records; do not leave charts out in the office area and do not place charts on the back of examination doors. 6. Computerized information must be safeguarded by: Password-secure access to all EMRs Computer monitor shields to protect patient information if data are left on the screen Turning monitors away from patient traffic areas to prevent accidental release of information
Asian patients may have difficulty maintaining eye contact during an interview. A . True B. False
A . True
Congruence is achieved when the communicator's words and body language are delivering the same message. A . True B. False
A . True
The chief complaint may also be called the patient's present illness. A . True B. False
A . True
The size and shape of a wound would be included in the objective area of the progress notes of SOAPE documentation. A . True B. False
A . True
When the medical assistant asks the patient about the duration of the symptoms, the question refers to the length of time the patient has had the symptoms. A . True B. False
A . True
A patient who accuses the medical assistant of being short tempered when the patient has just screamed at the medical assistant about a bill is displaying the defense mechanism of projection. A .True B. False
A .True
Detail how to make a correction in a patient's paper record.
A straight line is drawn through the error and the word "Error" is written above it; it is initialed and dated if the note does not have a date. The correction is then added.
During patient assessment, which of the following is an example of a subjective finding? A. Difficulty breathing B. Temperature C. Blood pressure and pulse D. Palpable mass
A. Difficulty breathing
Lois Anderson was recently diagnosed with a functional disorder of the colon. Which of the following is true about her condition? A. Her laboratory results are negative. B. A colonoscopy reveals abnormal tissue. C. Clinical signs indicate disease. D. None of the above is true.
A. Her laboratory results are negative.
Which of the following is a stage 3 requirement for Medicare and Medicaid EHR Incentive Program? A. Providers are expected to show improved patient outcomes. B. Maintain current patient medication list. C. Include lab test results in patient's EHR. D. Provide summary of care for patients transferring to another provider.
A. Providers are expected to show improved patient outcomes.
Which of the following involves repeating or paraphrasing the patient's comments? A. Restatement B. Clarification C. Reflection
A. Restatement
Sam Hernandez, a 17-year-old patient with burning upon urination, has just been told he has an STD. He had suspected that he had gonorrhea, but he states, "The test must be wrong. I just have a bladder infection." He is displaying which defense mechanism? A. Suppression B. Denial C. Regression D. Sublimation
A. Suppression
Which of the following is not true of holistic patient care? A. The focus of care is the patient's disease process. B. The physician considers the patient's ability to pay for treatment. C. The patient's emotional state is investigated. D. The medical assistant investigates lifestyle factors that may contribute to disease.
A. The focus of care is the patient's disease process.
A 6-year-old child who refuses to leave her mother's lap during a physical examination is displaying regression. A. True B. False
A. True
Gathering details about a patient's use of over-the-counter medications is very important during a patient interview. A . True B. False
A. True
Issues of privacy are important to adolescent patients. A. True B.False
A. True
Progress notes in the POMR include the use of SOAPE documentation. A. True B. False
A. True
Subjective data include the patient's report of injuries and resultant pain level. A. True B. False
A. True
The best method of ensuring that the patient understands a patient education intervention is to have the patient repeat back the details learned. A. True B. False
A. True
Value systems are learned beliefs and behaviors that can affect therapeutic relationships. A. True B. False
A. True
Which of the following is a good example of an open-ended question? A. What brings you to the doctor today? B. Do you have a headache? C. What is your date of birth? D. Have you ever broken a bone?
A. What brings you to the doctor today?
Therapeutic interactions with children include all of the following except A. allowing the child to decide whether a breathing treatment is needed. B. permitting the child to play with your stethoscope. C. praising the child for cooperative behavior. D. playing a game to distract the child.
A. allowing the child to decide whether a breathing treatment is needed.
The medical assistant is responsible for documenting all of the following information except the A. review of systems. B. family history. C. social history. D. allergies.
A. review of systems.
Information that you gather from a patient interview is considered A. subjective. B. objective. C. assessment. D. evaluation.
A. subjective.
Which of the following is a closed question or statement? A. "Tell me about your headaches." B. "Does your head hurt?" C. "How are you feeling?"
B. "Does your head hurt?"
Sally Tipoke, age 17, is scheduled for her first Pap test today. She appears anxious and scared. Choose the medical assistant's most appropriate statement. A. "There's no need to worry about the test. Dr. Smith never hurts anyone." B. "You look worried about the exam. Can I answer any questions?" C. "If you just think about something positive, it will be over before you know it." D. "Dr. Smith expects you to stay still during the exam."
B. "You look worried about the exam. Can I answer any questions?"
Mrs. Elizabeth Stewart was recently diagnosed with diabetes mellitus type 2. She refuses to meet with a dietician because, she states, "The tests must be wrong. No one in my family has diabetes." Which defense mechanism is she displaying? A. Sublimation B. Denial C. Repression D. Suppression
B. Denial
A patient interview may be conducted in a quiet corner of the waiting room. A. True B. False
B. False
A patient's lifestyle factors would be included in the family history section of the medical history. A. True B. False
B. False
A sign is a patient-reported indication of disease. A . True B. False
B. False
An example of an objective sign of disease is the patient's reported level of pain. A. True B. False
B. False
Children should always be given a choice whether to take their medication. A. True B. False
B. False
Documenting that the patient reports a headache of 3 days' duration is part of the objective data in the POMR record. A. True B. False
B. False
Giving advice when it is requested by a patient is an effective way of displaying concern. A. True B. False
B. False
If the medical assistant is caring for an aging patient who has difficulty hearing, he or she should ignore the patient and direct the interaction toward a family member. A . True B. False
B. False
It is acceptable to skip lines when documenting to give the physician room to enter a note after the patient has been seen. A . True B. False
B. False
It is important for the medical assistant to keep arms and legs crossed during an interview to communicate authority to the patient. A. True B. False
B. False
Providing patients with automatic reassurance when they express a concern is part of a therapeutic relationship. A. True B. False
B. False
Restatement is a valuable active listening technique, because it acknowledges the emotions displayed by the patient during the interview. A. True B. False
B. False
The SOMR begins with a list of the patient's health problems. A . True B. False
B. False
The easiest way to get specific information from the patient is to use open-ended questions. A. True B. False
B. False
The initial diagnosis made by the physician after completion of the physical examination is the differential diagnosis. A. True B. False
B. False
The medical assistant is responsible for performing the systems review. A. True B. False
B. False
The most effective distance between a patient and the medical assistant conducting an interview is approximately 2 to 3 feet. A. True B. False
B. False
The physician's decision to refer a patient to a dietician is documented under the assessment category of SOAP records. A . True B. False
B. False
When communicating with a sick child, it is important to direct all questions toward the child's parent. A. True B. False
B. False
When conducting a patient interview, the medical assistant should sit behind a desk with arms crossed and wait for the patient to establish eye contact. A. True B. False
B. False
During a physical examination the patient reports problems with speech and balance. These signs indicate a problem with which system? A. Respiratory B. Neurologic C. Cardiovascular D. Lymph
B. Neurologic
Which of the following are learned behaviors that are greatly influenced by our family and cultural backgrounds? A. Active listening B. Nonverbal communication C. Verbal messages D. None of the above
B. Nonverbal communication
Which of the following includes childhood diseases? A. Family history B. Past history C. Social history D. Database E. ROS
B. Past history
Which medical record system has a standard format that makes it easy to read and audit? A. Chronologic B. Problem oriented C. Progress note D. Source oriented
B. Problem oriented
What does it mean when medical assistants display empathy when dealing with patients? A. They feel sorry for patients who have serious health problems. B. They are able to hear what patients say without judging the content. C. They can detach themselves emotionally from the problems of their patients. D. They truly like and care about each of their patients.
B. They are able to hear what patients say without judging the content.
Abnormalities in the cardiovascular system that are discovered during an ROS include A. deformity of the chest. B. hypertension and leg cramps. C. deviated septum. D. jaundice.
B. hypertension and leg cramps.
A medical assistant who is a good listener consistently A. provides repeated assurances. B. provides feedback to clarify the patient's message. C. interrupts the patient to gather more details. D. limits the amount of time spent on each interview.
B. provides feedback to clarify the patient's message.
Research on the significance of body language indicates that 50% of the message received by patients is interpreted from the caregiver's nonverbal language. A. True B. False
B.False
Which of the following questions or statements would encourage the patient to continue to communicate? A. "Does your arm hurt?" B. "Did you hurt yourself?" C. "Tell me about how your arm feels right now." D. "Do you have a family history of arthritis?"
C. "Tell me about how your arm feels right now."
Which of the following is an open-ended question or statement? A. "How old are you?" B. "Do you smoke?" C. "What brings you to the office today?"
C. "What brings you to the office today?"
When writing progress (SOAP) notes, in which section would the provider's preliminary diagnosis of the cause of the patient's chief complaint be placed? A. S B. O C. A D. P
C. A
Objective data include which of the following? A. Complaints of pain B. Social history C. Blood pressure recordings D. Past medical history
C. Blood pressure recordings
Which of the following processes involved in active listening seeks to summarize or simplify the sender's thoughts and feelings or to resolve any confusion in the message? A. Restatement B. Reflection C. Clarification D. Feedback
C. Clarification
Which of the following is most important when conducting a patient interview? A. Calling the patient by his or her first name B. Sharing stories about the neighborhood C. Providing uninterrupted privacy D. Documenting every word the patient uses to describe the health problem
C. Providing uninterrupted privacy
Which of the following involves stating an observation or recognition of a patient's feeling? A. Restatement B. Clarification C. Reflection
C. Reflection
Which type of data collection is NOT associated with holistic care? A. Physical B. Cognitive C. Social D. Behavioral
C. Social
Which of the following includes the patient's dietary habits, smoking history, and alcohol consumption? A. Family history B. Past history C. Social history D. Database E. ROS
C. Social history
Which of the following factors is likely to have the most influence on the accuracy and completeness of the information obtained from the patient during the medical history? A. The comfort of the chairs in the meeting area B. The medical assistant's ability to take complete and detailed notes C. The privacy of the area in which the interview takes place D. The efficiency of the medical assistant in conducting the interview
C. The privacy of the area in which the interview takes place
Which statement best describes what it means to have good rapport with patients? A. You use language they understand. B. They respect you as a professional. C. You have smooth, pleasant relationships with them. D. You are polite and punctual.
C. You have smooth, pleasant relationships with them.
Which of the following is considered a safeguard mandated by HIPAA? A. Passwords access to all electronic health records B. Computer monitor shields C. Turning monitors away from patient traffic areas D. All of the above
D. All of the above
While you are taking the medical history of a new patient, the patient mentions having occasional headaches that are quite painful. What is the best way for you to proceed with the interview? A. Express concern and note this information in writing. B. Ask the patient a direct question about the pain. C. Reassure the patient that it is probably nothing serious. D. Ask the patient open-ended questions about the headaches.
D. Ask the patient open-ended questions about the headaches.
Which of the following includes demographic information? A. Family history B. Past history C. Social history D. Database E. ROS
D. Database
Which of the following includes insurance information? A. Family history B. Past history C. Social history D. Database E. ROS
D. Database
When writing in a paper record and an error is made, which of the following document guidelines is acceptable? A. Scribble out error. B. Use whiteout to cover up the error. C. Erase the error. D. Draw a line through the error.
D. Draw a line through the error.
Which of the following explains a sign of disease? A. Patient c/o pain B. Reports of dizziness for 3 days C. Abdominal cramping for 2 weeks D. Elevated blood pressure
D. Elevated blood pressure
Which of the following components of the medical history provide a guide to the patient's general health? A. Chief complaint B. Family history C. Social history D. Systems review
D. Systems review
During the physical examination, the patient reports a continual ache in the right elbow. This information is called a(n) A. functional problem. B. objective finding. C. sign. D. symptom
D. symptom
The section of the medical history that helps uncover existing or potential health problems is called the A. database. B. past history. C. social history. D. systems review.
D. systems review.
Your office manager asks whether you know anything about defense mechanisms that patients might display if they are anxious. Summarize four defense mechanisms and provide an example of each.
Denial: The patient completely rejects the information. "I couldn't possibly have breast cancer. You must be mistaken." Suppression: The patient is consciously aware of the information or feeling but refuses to admit it. "I don't think the test is accurate. My mammograms are always normal." Reaction formation: The patient expresses her feelings as the opposite of what she really feels. For example, if she is angry at the medical assistant for insisting that a biopsy be scheduled, the patient may express the opposite emotion. "I appreciate your trying to help me, but I just can't come to the hospital that day." Projection: The patient accuses someone else of having feelings she possesses. For example, if the patient is angry about the diagnosis, she may say to the medical assistant, "You don't have to lose your temper about this," even though the medical assistant is acting completely professional. Rationalization: The patient comes up with various explanations to justify her response. "I think the results are wrong. I didn't follow the directions for the tests like I should have, and besides, there's no history of breast cancer in my family." Undoing: The patient tries to reverse a negative feeling by doing something that indicates the opposite feeling. If the patient feels angry and violated about the diagnosis but she finds those feelings unacceptable, she may say, "Don't worry dear, I'm not upset with you for telling me about this." Regression: The patient reverts to an old, usually immature behavior to ventilate her feelings. Perhaps instead of discussing the diagnosis and need for treatment, she just storms out of the office. Or she may say, "I can't possibly schedule a procedure without discussing this with my mother." Sublimation: The patient redirects her negative feelings into a socially productive activity. For example, Mrs. Simone eventually becomes an active member of a local support group for women recovering from breast cancer.
Helen Conrad, age 54, was recently diagnosed with epilepsy. She is very upset about the news. A therapeutic interaction might be A. "Look on the bright side; things could be worse." B. "The doctor will prescribe medication, which will probably prevent most seizures." C. Distract the patient by discussing the weather. D. Offer the patient advice on how to drive safely. E. Listen attentively while the patient talks about her fears.
E. Listen attentively while the patient talks about her fears.
Which of the following sections of the medical record includes the physical examination findings? A. Family history B. Past history C. Social history D. Database E. ROS
E. ROS
You are conducting an interview with a new patient who appears very anxious. Summarize four ways of using therapeutic nonverbal language to enhance the quality of the patient interaction.
Establish eye contact, control overuse of gestures but nod head as needed to indicate interest and empathy, do not allow furniture to create a barrier from the patient, lean toward the patient to communicate interest, communicate with the patient at his or her level, use an even tone of voice, and reflect your interest in your facial expressions.
The __________ in POMR charts lists the patient's diagnoses in chronologic order.
0. problem list
__________ data include the patient's blood pressure, TPR, and weight.
0. Objective
__________ are subjective reports given by patients about how they feel with a particular health problem.
0. Symptoms
__________ is an attempt by the patient to hide a negative feeling he or she believes is unacceptable by doing the exact opposite.
0. Undoing
The __________ of the interview should summarize the information the medical assistant learned while communicating with the patient and should outline patient expectations of care.
0. closing
When a verbal message matches the sender's nonverbal body language, the message is considered __________.
0. congruent
The __________ component of the medical history contains details about the patient's insurance, address, and date of birth.
0. database
When SOAPE documentation is used, the __________ documentation provides feedback on the results of treatment.
0. evaluation
The medical assistant must consistently request __________ from the patient to determine the patient's understanding of the message.
0. feedback
During the __________ phase of the interview, medical assistants should introduce themselves and state the purpose of the interview.
0. initiation
A detailed description of the anatomic location of a wound would be documented in the __________ area of a SOAPE format.
0. objective
The __________ is the physician's approach to managing the patient's health problem.
0. plan
