Documentation

Which part of a health history includes information about the patient's reason for seeking medical help?

Chief complaint

What is the best way for health care workers to elicit the greatest amount of information from patients?

Ask broad questions.

Which type of documentation has a purpose of releasing the patient back to their regular lifestyle and giving a record of the interactivity among health care providers?

Discharge report

Which of the following is true of documentation?

Documentation is perhaps the most critical communication that a health care worker will create.

What is the benefit of using SOAP notes?

Employees know where to look for information.

How should subjective statements by the patient be documented?

Exact words in quotation marks

Which type of documentation has a purpose of assessing the patient's condition, planning for treatment, and contains the goals for recovery?

Initial evaluation

Which of the following describes all parts of a patient's health history?

It is confidential.

What type of note-taking method describes how a patient's treatment has changed?

Narrative

Which type of documentation has a purpose of supporting and giving evidence of the need for the patient's continued medical care?

Progress report

Which part of a health history includes information about the patient's lifestyle?

Psychosocial history

Which of the following is NOT a standard of documentation that should be followed by health care workers?

Record information performed or observed by another health care worker.

What is another term for "symptom"?

Subjective observation