Medical Records Documentation

Patient records are essential for patient care management and also used for ____.

• advertising physician services

• providing patient education

• providing patient education

Patient records are used in medical research __________

• or data regarding patient responses and side effects

• only occasionally, because it is usually considered illegal

• as a means to get research money

A patient’s illness and the reason for a visit to the medical office are found in the ____.

• informed consent form

• patient medical history

• patient registration form

The purpose of having a patient sign an informed consent form is to ensure that the ____.

• patient has a legal recourse against the physician

• physician may terminate care at any time

• patient understands the treatment and the possible outcomes

The most appropriate way to terminate an initial interview with the patient is ____.

• "The doctor will be in shortly."

• "Is there anything else you would like the doctor to know?"

• "I need to terminate this interview."

The best place to interview a patient is _____________

• in a private room

• in the patient waiting room

• at the reception desk

The patient got out of bed and walked 20 ft without or displaying signs of shortness of breath...

• too much detail

• using the client's words

• clarity

An example of a patient sign is ____.

• pain

• nausea

• rash

An example of a patient symptom is ____

• pain

• high blood pressure

• swelling

The S section of SOAP documentation is ____

• the diagnosis or impression of a patient's problem

• answer data that comes directly from the patient

• the plan of action