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Chapter 11 Medical Records Test

Quiz by Kelly Tabor

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16 questions
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  • Q1
    A thorough review

    Conversation

    Discharge

    Physical

    Audit
    30s
  • Q2
    CHEDDAR

    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 referral
    30s
  • Q3
    Relating to the structure of populations
    Demographic

    Treatment

    Demonstration

    Diagnosis

    30s
  • Q4
    Recording of pertinent data on the clinical record
    Documentation

    Referral

    Co-Pays

    Insurance

    30s
  • Q5
    Pt who is refusing or failing to follow instructions is considered:

    Sign

    non compliant

    Objective

    compliant

    30s
  • Q6
    Anything that can be seen or measured is as/a:

    Subjective

    Objective

    Symptom

    Obstructive

    30s
  • Q7
    A compilation of a patient's health information.
    Patient record

    Data Record

    Demographic

    Compliant Record

    30s
  • Q8
    POMR

    purpose-oriented medical record

    parental-oriented medical record

    problem-oriented medical record

    personal-oriented medical record

    30s
  • Q9
    physical examination of all body systems in a systematic manner as part of the medical assessment
    Review of Systems (ROS)
    30s
  • Q10
    What the patient tells us is wrong.....I have a sore throat. It is known as:/a:

    Sign

    Objective

    Issue

    Subjective
    30s
  • Q11
    A sign or indication of something that appears to be the problem.

    Sign

    Serious

    Sacral

    Sympton
    30s
  • Q12
    SOMR

    Source oral medical record

    Source optical medical record

    Source oriented medical record

    Source objective medical record

    30s
  • Q13
    subjective, objective, assessment, plan

    OSPA

    SAOP

    SOAP

    SPOA

    30s
  • Q14
    Objective evidence such as a  disease,  such as a fever is considered a:

    Symptom

    Signal

    Sign

    Surgery

    30s
  • Q15
    Transcription is the process by which the spoken word (verbal) is spoken into written word

    Description

    Transcription

    Prescription

    Inscription

    30s

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