Chapter 2. Introduction to Health Records

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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


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