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Medical Records Documentation

Total questions: 10

Worksheet time: 6mins

Name
Class
Date
1.

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

a)

advertising physician services

b)

providing patient education

c)

providing patient education

2.

Patient records are used in medical research __________

a)

or data regarding patient responses and side effects

b)

only occasionally, because it is usually considered illegal

c)

as a means to get research money

3.

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

a)

informed consent form

b)

patient medical history

c)

patient registration form

4.

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

a)

patient has a legal recourse against the physician

b)

physician may terminate care at any time

c)

patient understands the treatment and the possible outcomes

5.

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

a)

"The doctor will be in shortly."

b)

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

c)

"I need to terminate this interview."

6.

The best place to interview a patient is _____________

a)

in a private room

b)

in the patient waiting room

c)

at the reception desk

7.

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

a)

too much detail

b)

using the client's words

c)

clarity

8.

An example of a patient sign is ____.

a)

pain

b)

nausea

c)

rash

9.

An example of a patient symptom is ____

a)

pain

b)

high blood pressure

c)

swelling

10.

The S section of SOAP documentation is ____

a)

the diagnosis or impression of a patient's problem

b)

answer data that comes directly from the patient

c)

the plan of action