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WorksheetsMedical Records Documentation
Total questions: 10
Worksheet time: 6mins
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
