Exam 21: Patient Assessment

Progress notes in the POMR include the use of SOAPE documentation.

Asian patients may have difficulty maintaining eye contact during an interview.

During the __________ phase of the interview, medical assistants should introduce themselves and state the purpose of the interview.

Sam Hernandez, a 17-year-old patient with burning upon urination, has just been told he has an STD. He had suspected that he had gonorrhea, but he states, "The test must be wrong. I just have a bladder infection." He is displaying which defense mechanism?

Which medical record system has a standard format that makes it easy to read and audit?

When writing in a paper record and an error is made, which of the following document guidelines is acceptable?

The __________ of the interview should summarize the information the medical assistant learned while communicating with the patient and should outline patient expectations of care.

The __________ component of the medical history contains details about the patient's insurance, address, and date of birth.

Which of the following components of the medical history provide a guide to the patient's general health?

When SOAPE documentation is used, the __________ documentation provides feedback on the results of treatment.

__________ are subjective reports given by patients about how they feel with a particular health problem.

Which type of data collection is NOT associated with holistic care?

Which of the following processes involved in active listening seeks to summarize or simplify the sender's thoughts and feelings or to resolve any confusion in the message?

Which of the following involves stating an observation or recognition of a patient's feeling?

The medical assistant is responsible for performing the systems review.

Documenting that the patient reports a headache of 3 days' duration is part of the objective data in the POMR record.

During the physical examination, the patient reports a continual ache in the right elbow. This information is called a(n)

The medical assistant must consistently request __________ from the patient to determine the patient's understanding of the message.

Which of the following includes insurance information?

Children should always be given a choice whether to take their medication.