WorksheetsMedical Records Management - History Taking Questions 3
Total questions: 47
Worksheet time: 24mins
An example of a question to ask during history taking is: Is the patient eating normally?
Is the patient eating normally?
What is the patient's favorite color?
Does the patient enjoy watching movies?
Is the patient left-handed?
The patient is fed:
through a feeding tube
by mouth
intravenously
with supplements only
An example of a question to ask during history taking is:
When was the last meal?
What is your favorite color?
How many siblings do you have?
Do you like sports?
How much did the patient eat?
Amount of food consumed by the patient
Type of food eaten by the patient
Time of the patient's last meal
Patient's favorite food
During history taking, which of the following is an example of a question to ask about treats?
Any treats? If yes, what treats? How often?
What is the pet's favorite toy?
How many hours does the pet sleep?
Does the pet like to go for walks?
The patient is drinking the same amount of water as usual.
Yes
No, drinking less
No, drinking more
Not sure
The patient drinks water:
Regularly
Rarely
Never
Only after meals
Vomiting: Frequency of vomiting in the pet is:
Rarely
Frequently
Never
Occasionally
Vomiting: The color of the vomit is:
Green
Blue
Purple
Black
Vomiting: The vomit consists of:
partially digested food
blood cells
bone fragments
saliva only
Vomiting: The pet has eaten toys, blankets, or towels.
Yes
No
Sometimes
Not sure
In the context of Medical Records Management, what does POMR stand for?
Problem-oriented medical records
Patient-operated medical records
Physician-ordered medical reports
Personalized outpatient medical records
Which of the following is NOT a component of SOAP in Problem-oriented medical records?
Subjective
Objective
Assessment
Prescription
Plan
In SOAP notes, the 'Subjective' section includes which of the following?
PE, diagnostics, medical interpretation
The reason for the visit
Conclusions reached using S/O sections
Rule-outs, rule-ins, Ddx
In SOAP notes, the 'Objective' section includes ________, diagnostics, and medical interpretation.
PE
HPI
ROS
Assessment
In SOAP notes, which section involves conclusions reached using S/O sections and rule-outs, rule-ins, Ddx?
Assessment
Subjective
Objective
Plan
The 'Plan' is a component of SOAP in Problem-oriented medical records.
True
False
What type of tests are CBC and Chemistry lab results?
Blood tests
Urine tests
Imaging tests
Allergy tests
The client noticed the dog appears lethargic lately. What symptom did the client notice in the dog?
Lethargy
Vomiting
Coughing
Itching
The cat may have renal disease or diabetes. Which two conditions are suspected in the cat?
Renal disease, diabetes
Arthritis, obesity
Asthma, hyperthyroidism
Pancreatitis, anemia
What diagnostic tool is mentioned in the worksheet?
Radiographs
Stethoscope
Thermometer
Blood Pressure Cuff
The client may proceed with surgical excision with histopathology or chemotherapy. What are the two possible next steps for the client?
Surgical excision with histopathology, chemotherapy
Radiation therapy, physical therapy
Observation, dietary modification
Antibiotic therapy, immunization
What was the result of the Parvo test?
Positive
Negative
Inconclusive
Not Performed
The vomiting is either caused by foreign obstruction or GI upset. What are the two possible causes of vomiting mentioned?
Foreign obstruction, GI upset
Dehydration, fever
Allergy, infection
Liver failure, kidney stones
According to Medical Records Management, what must a medical record include? ________ exam.
Physical exam
Written exam
Oral exam
Vision exam
According to Medical Records Management, what must a medical record include? ________ (related to possible conditions).
Differentials
Medications
Allergies
Procedures
According to Medical Records Management, what must a medical record include? ________ (the identification of the disease or condition).
Diagnosis
Prescription
Allergy
Appointment
According to Medical Records Management, what must a medical record include? Lab ________.
interpretation
temperature
duration
location
According to Medical Records Management, what must a medical record include? ________ (the likely course or outcome of the disease).
Prognosis
Diagnosis
Prescription
Allergy
According to Medical Records Management, what must a medical record include if the patient is hospitalized? Progress ________.
notes
charts
medications
orders
Medical Records Management: Which of the following is the correct way to document the administration of Cefazolin?
0.2 mL Cefazolin IV
0.2 mL Cefazolin (100 mg/mL) given IV
20 mg Cefazolin, given IV
Both B and C
Medical Records Management: The same drug can also be administered by different _______ (some drugs will have a different dose depending on the route administered).
routes
colors
brands
flavors
Identify the type of fluid administered.
Type of fluid administered (e.g., saline, dextrose, etc.)
Type of medication administered (e.g., antibiotics, analgesics, etc.)
Type of equipment used (e.g., syringe, IV set, etc.)
Type of procedure performed (e.g., intubation, catheterization, etc.)
Identify how many mL/kg/hr were administered.
Amount in mL/kg/hr (e.g., 10 mL/kg/hr)
5 mL/kg/hr
20 mL/kg/hr
50 mL/kg/hr
Administration of fluids must also be documented clearly. Identify the route of administration.
Route of administration (e.g., intravenous, oral, subcutaneous)
Type of fluid (e.g., saline, dextrose)
Patient's age and weight
Time of day the fluid is given
How many years is it commonly required to maintain medical records according to state regulations?
3 years
1 year
5 years
10 years
How many states require medical records to be maintained for 7 years?
Two states
Five states
Ten states
Twenty states
What should be done with all purged medical records?
Shred all purged medical records
Store them in a public archive
Donate them to a library
Send them to patients' families
Since vaccine protocols have changed to every 3 years, is it important to maintain records for more than 3 years?
True
False
What is the definition of inactive records according to the image?
Clients that have not visited the practice within 1 year
Clients that have visited the practice within 1 year
Clients that have never visited the practice
Clients that visit the practice every month
Can inactive records be moved to another location within the practice?
True
False
Reducing the number of records on the active section reduces ________, misplaced, and misfiled records.
lost
found
archived
shared
Clients must receive __________ to take home as part of discharge instructions.
information
medication
equipment
transportation
Clients cannot remember all __________ presented to them in the practice.
information
colors
locations
numbers
It is important to verbally review with __________ before giving documents during client discharge.
owner
receptionist
neighbor
technician
Use __________ copies for client discharge instructions.
carbonless
photocopy
handwritten
scanned
Have clients __________ that they received instructions during discharge.
initial
refuse
ignore
forget
