Question 1

Explain why a problem list is maintained.

Accepted Answer

Answers will vary. Two explana

Question 2

Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low-grade fever for the past four days. This is known as _______________.

Accepted Answer

A)  subjective information 
B)  objective information 
C)  an assessment 
D)  a diagnosis 
A)  subjective information 
B)  objective information 
C)  an assessment 
D)  a diagnosis

Question 3

Dr. Clark has just documented his findings of a physical exam performed on Patti Wolfe. She was seen today for productive cough. These findings are considered what kind of findings, as they relate to the SOAP note?

Accepted Answer

The answer of Dr. Clark has just documented his findings...

Question 4

Why did the patient seek care?

Accepted Answer

The patient was complaining of

Question 5

A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).

Accepted Answer

A)  associated signs and symptoms 
B)  modifying factors 
C)  severity 
D)  location 
A)  associated signs and symptoms 
B)  modifying factors 
C)  severity 
D)  location

Question 6

Which of the following is a benefit of voice recognition technology?

Accepted Answer

A)  The cost is lower to implement. 
B)  From the beginning it is less time consuming for the care provider. 
C)  Documents are made part of the patient's record in a timelier manner. 
D)  One hundred percent accuracy is attainable. 
A)  The cost is lower to implement. 
B)  From the beginning it is less time consuming for the care provider. 
C)  Documents are made part of the patient's record in a timelier manner. 
D)  One hundred percent accuracy is attainable.

Question 7

In order for any test, procedure, or medication to be administered to a patient, there must be a

Accepted Answer

A)  SOAP note. 
B)  history and physical exam. 
C)  care provider's order. 
D)  consent from the patient. 
A)  SOAP note. 
B)  history and physical exam. 
C)  care provider's order. 
D)  consent from the patient.

Question 8

Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information.

Accepted Answer

A)  Transcriptionists 
B)  Scribes 
C)  Dictators 
D)  Nurses 
A)  Transcriptionists 
B)  Scribes 
C)  Dictators 
D)  Nurses

Question 9

Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________________ data.

Accepted Answer

A)  structured 
B)  unstructured 
C)  quantitative 
D)  qualitative 
A)  structured 
B)  unstructured 
C)  quantitative 
D)  qualitative

Question 10

The healthcare professional who types reports for care providers is known as a/an ______________.

Accepted Answer

A)  dictator 
B)  transcriptionist 
C)  transcriber 
D)  scribe 
A)  dictator 
B)  transcriptionist 
C)  transcriber 
D)  scribe

Question 11

Explain the benefits of ePrescribing.

Accepted Answer

Answers will vary. The process of the ph

Question 12

A history of present illness will usually consist of which elements?

Accepted Answer

The HPI will usually include location of

Explain why a problem list is maintained.

Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low-grade fever for the past four days. This is known as _______________.

Dr. Clark has just documented his findings of a physical exam performed on Patti Wolfe. She was seen today for productive cough. These findings are considered what kind of findings, as they relate to the SOAP note?

Why did the patient seek care?

A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).

Which of the following is a benefit of voice recognition technology?

In order for any test, procedure, or medication to be administered to a patient, there must be a

Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information.

Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________________ data.

The healthcare professional who types reports for care providers is known as a/an ______________.

Explain the benefits of ePrescribing.

A history of present illness will usually consist of which elements?

An Overview of Prime Suites Practice Management and Electronic Health Record Software

Health Data Structure, Collection, and Standards

Content of the Health Recordadministrative Data

Content of the Health Recordthe Past Medical, Surgical, Family, and Social Histories

Financial Management: Insurance and Billing Functions

Privacy, Security, Confidentiality, and Legal Issues

Management of Information and Communication

Decision and Compliance Support: Utilizing the Database

Looking Aheadthe Future of Health Information and Informatics

Filters

Exam 5: Content of the Health Recordthe Care Providers Responsibility

Explain why a problem list is maintained.

Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low-grade fever for the past four days. This is known as _______________.

Dr. Clark has just documented his findings of a physical exam performed on Patti Wolfe. She was seen today for productive cough. These findings are considered what kind of findings, as they relate to the SOAP note?

Why did the patient seek care?

A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).

Which of the following is a benefit of voice recognition technology?

In order for any test, procedure, or medication to be administered to a patient, there must be a

Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information.

Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________________ data.

The healthcare professional who types reports for care providers is known as a/an ______________.

Explain the benefits of ePrescribing.

A history of present illness will usually consist of which elements?

An Overview of Prime Suites Practice Management and Electronic Health Record Software

Health Data Structure, Collection, and Standards

Content of the Health Recordadministrative Data

Content of the Health Recordthe Past Medical, Surgical, Family, and Social Histories

Financial Management: Insurance and Billing Functions

Privacy, Security, Confidentiality, and Legal Issues

Management of Information and Communication

Decision and Compliance Support: Utilizing the Database

Looking Aheadthe Future of Health Information and Informatics

Filters