Chapter 11 Medical Records Test
Quiz by Kelly Tabor
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- Q1A thorough review
Conversation
Discharge
Physical
Audit30sEditDelete - Q2CHEDDAR
chief complaint, history of present illness examination, details, drugs and dosages, assessment, return visit information or no referrals
chief complaint, history of present illness examination, no details, drugs and dosages, assessment, return visit information or referral
chief compliance, history of present illness examination, details, drugs and dosages, assessment, return visit information or referral
chief complaint, history of present illness examination, details, drugs and dosages, assessment, return visit information or referral30sEditDelete - Q3Relating to the structure of populationsDemographic
Treatment
Demonstration
Diagnosis
30sEditDelete - Q4Recording of pertinent data on the clinical recordDocumentation
Referral
Co-Pays
Insurance
30sEditDelete - Q5Pt who is refusing or failing to follow instructions is considered:
Sign
non compliantObjective
compliant
30sEditDelete - Q6Anything that can be seen or measured is as/a:
Subjective
ObjectiveSymptom
Obstructive
30sEditDelete - Q7A compilation of a patient's health information.Patient record
Data Record
Demographic
Compliant Record
30sEditDelete - Q8POMR
purpose-oriented medical record
parental-oriented medical record
problem-oriented medical recordpersonal-oriented medical record
30sEditDelete - Q9physical examination of all body systems in a systematic manner as part of the medical assessmentReview of Systems (ROS)30sEditDelete
- Q10What the patient tells us is wrong.....I have a sore throat. It is known as:/a:
Sign
Objective
Issue
Subjective30sEditDelete - Q11A sign or indication of something that appears to be the problem.
Sign
Serious
Sacral
Sympton30sEditDelete - Q12SOMR
Source oral medical record
Source optical medical record
Source oriented medical recordSource objective medical record
30sEditDelete - Q13subjective, objective, assessment, plan
OSPA
SAOP
SOAPSPOA
30sEditDelete - Q14Objective evidence such as a disease, such as a fever is considered a:
Symptom
Signal
SignSurgery
30sEditDelete - Q15Transcription is the process by which the spoken word (verbal) is spoken into written word
Description
TranscriptionPrescription
Inscription
30sEditDelete - Q16
What is 65 inches in feet and inches.
5 foot 5 inches
5 foot 3 inches
6 foot 5 inches
5 foot 6 inches
30sEditDelete