Exam 5: Content of the Health Recordthe Care Providers Responsibility

Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the __________________ system.

Relating to dictation, the technology that does recognize individual voices and does not improve over time is which kind of technology?

How does a patient whose care is rendered at a physician's office with computerized physician order entry capability benefit? Give an example.

Relate the reason(s) why voice recognition software is eventually more cost efficient for a physician's practice or hospital.

In healthcare, when something is occurring at the time the patient is being seen, such as in ePrescribing, this is known as ____________________.

Emily Haver is being seen by Dr. Clark today for her annual physical exam. She has been a patient of his for many years. She is currently being treated for hypertension and type 2 diabetes mellitus. In the late 1990s she was treated on several occasions for poison ivy. She has been treated since 2003 with Zoloft for mild depression. Of the following, which will not appear on Emily Haver's problem list?

If a computerized physician's order is sent to the local hospital for a blood test, and the physician's office has already been notified of the test findings, this order is

What information is considered to be part of the history of present illness (HPI)?

Which of the following is an advantage of dictation and transcription?

The results of a patient's rapid strep test would be found in what area of a SOAP note?

How does order tracking benefit the patient?

Of the following, which is an element of the history of present illness (HPI)?

During the history, Kevin Goodell notes that the pain in his right hip is more of a dull pain than an ache. This is considered what part of the history of present illness (HPI)?

In Prime Suite, as with many other electronic health record systems, healthcare professionals and healthcare providers can access a patient's health record to determine the status of orders for testing or prescriptions. This is known as

The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient's visit.

One of the reasons ePrescribing is being used by a greater number of physicians' practices is that it

How a patient is feeling, any current complaints or concerns, weight loss or gain, appetite, sleep patterns or difficulties, and a recap of vital signs are documented in the general part of the ROS and is also known as what?

Alison Holt just received a copy of her Clinical Visit Summary from the visit to her primary care provider earlier in the day. She is reading that her symptoms were present for the past four days and that she did not get any relief from Motrin. To which section of the SOAP note does this information pertain?

Kelly is being seen by her physician today, and he is asking her if she's had any increase in or unusual headaches since her last visit, whether she has any blurred vision, and whether she has seen her eye doctor in the past year. The answers to these and other questions are documented in what part of the health record?

In a hospital setting, the care provider takes the patient's history, details the reason the patient is being admitted, and performs a physical exam. The report of this information is known as the: