Health Record and Documentation Quiz

What does the 'S' in a SOAP note stand for?

• Severity

• Subjective

• Sensation

• Symptoms

Which component of the SOAP note includes measurable or observable findings?

• Subjective

• Assessment

• Objective

• Plan

What does the 'A' in a SOAP note represent?

• Anamnesis

• Analysis

• Assessment

• Action

What is the purpose of a discharge summary?

• To perform a physical exam

• To prescribe medications

• To order tests

• To summarize a patient's hospital stay

What is the difference between unstructured data and structured data in health records?

• Unstructured data is only used in inpatient settings, while structured data is used in outpatient settings

• Unstructured data is chosen from pre-formatted fields, while structured data is handwritten or typed

• Unstructured data is handwritten or typed, while structured data is chosen from pre-formatted fields

• Unstructured data is used for physical exams, while structured data is used for SOAP notes

What is the purpose of the history of present illness (HPI) in a health record?

• To order tests

• To prescribe medications

• To document the patient's current complaints

• To summarize the patient's hospital stay

What is the review of systems (ROS) based on?

• Laboratory results

• Patient's responses

• Care provider's observations

• Physical exam findings

What is the purpose of electronic prescribing (ePrescribing)?

• To order tests

• To perform physical exams

• To document the patient's current complaints

• To electronically transmit prescriptions from care provider to pharmacy

What is the function of computerized physician order entry (CPOE)?

• Assisting care providers in entering data into the health record

• Transcribing dictated notes into typed documents

• Recognizing the words being said by the person dictating

• Entering orders electronically and transmitting them directly to the appropriate department

What is the purpose of the problem list in a health record?

• To summarize the patient's hospital stay

• To enter data into the health record as the care provider verbally dictates recent findings

• To electronically transmit prescriptions from care provider to pharmacy

• To list all of the patient's current and resolved medical conditions