WorksheetsCP1: Ch 1 Review
Total questions: 11
Worksheet time: 6mins
A function of the medical record is to share information with the patient's family.
True
False
Which of the following would be an appropriate response to the "quality" field for the HPI?
5/10
2 weeks
constant
aching
Which of the following would be appropriate to document in the "modifying factors" field of the HPI?
5/10
intermittant
worse upon waking up
stabbing
Why should lab or outside appointments (mammograms, etc.) always be documented in the medical record?
to avoid reduction of credibility.
to provide documentation in case the patient does not undergo the appointment.
to ensure the patient receives proper care.
all of the above.
What is the ROS?
A systematic review of each body system
The symptom causing the patient the most trouble
A history of the patient’s previous diseases, injuries, and operations
A review of the hereditary diseases and health of blood relatives
Which term means excessive perspiration:
jaundice
edema
malaise
diaphoresis
Which of the following would be an appropriate CC?
ear pain and fever
fell on ice 1 day ago
fever and rash for 2 days
patient states they have pneumonia for 3 days
Which of the following situations requires the completion of a release of medical information form?
Patient referral to a specialist
When a patient transfers records to a new physician
Training of healthcare students
Emergency care provided at a hospital
Which of the following is an example of a diagnostic procedure:
physical therapy
antibiotic therapy
ear irrigation
chest x-ray
Why is it important to document any instructions provided to the patient?
To ensure the patient follows the instructions
To ensure that the patient understands the instructions provided
To protect the physician legally if the patient is harmed by not following the instructions
To provide a record for the insurance company
An example objective symptom would be:
rash
headache
abdominal pain
dizziness
