Exam 5: Content of the Health Recordthe Care Providers Responsibility

Which of the following is a benefit of CPOE?

A patient with knee pain has been using pain patches to alleviate the pain; she has been using the kind that are left on the area for several hours. Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI).

In a hospital setting, what document is the equivalent of the assessment and plan that is collected as part of a SOAP note in an outpatient record?

Which of the following professionals would not perform a physical examination (PE)?

Explain the difference between voice recognition and speech recognition technology. Why would one be preferred over the other by a care provider?

The SOAP documentation format is most commonly used in which healthcare setting?

A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as

The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?

The fact that a patient has taken an over-the-counter medication and received relief of his pain is known as what in relation to the subjective documentation found in this patient's chart?

What is required in order for computerized physician order entry to occur between different healthcare facilities?

The extent of a physical exam will depend largely on the reason for the patient's visit, which is otherwise known as what?

What information is considered to be part of the review of systems (ROS)?

Meaningful Use guidelines require the keeping of an up-to-date

In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital, a/an ____________________ must exist between the two computer systems.

Explain why a care provider's dictated and transcribed report would be more beneficial than a handwritten note.

What were the physical exam findings from the physical exam performed on Patti Wolfe?

Of the following, which is a benefit of ePrescribing?

LaRhonda Howard is seen today by Dr. Bilkins for a chief complaint of recurrent abdominal pain and loss of appetite. Robert Drew is seen today by Dr. Bilkins for a chief complaint of follow-up for his poison ivy, which he was treated for last week. Which of these patients is likely to have a more extensive physical exam?

Tiffany Randall is seen by her physician after falling off a piece of playground equipment. She has a laceration on her chin. This is part of which element of the history of present illness?

Dr. Schultz has just examined Natalia Shrier who had come to see him because she has been having increasing problems with gastroesophageal reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to avoid eating within three hours of going to bed, to raise the head of her bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's instructions are part of which element in a SOAP note?