Question 1

The position on a clock, topographic notations, and anatomic landmarks:

Accepted Answer

A)  are methods for recording locations of findings. 
B)  are used for noting disease progression. 
C)  are ways for recording laboratory study results. 
D)  should not be used in the legal record. 
A)  are methods for recording locations of findings. 
B)  are used for noting disease progression. 
C)  are ways for recording laboratory study results. 
D)  should not be used in the legal record.

Question 2

The examiner's evaluation of a patient's mental status belongs in the:

Accepted Answer

A)  history of present illness. 
B)  review of systems. 
C)  physical examination. 
D)  patient education. 
A)  history of present illness. 
B)  review of systems. 
C)  physical examination. 
D)  patient education.

Question 3

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record?

Accepted Answer

A)  Chief complaint 
B)  History of present illness 
C)  Past medical history 
D)  Social history 
A)  Chief complaint 
B)  History of present illness 
C)  Past medical history 
D)  Social history

The position on a clock, topographic notations, and anatomic landmarks:

The examiner's evaluation of a patient's mental status belongs in the:

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record?

The History and Interviewing Process

Cultural Competency

Examination Techniques and Equipment

Clinical Reasoning

Vital Signs and Pain Assessment

Mental Status

Growth, Measurement, and Nutrition

Skin, Hair, and Nails

Lymphatic System

Head and Neck

Eyes

Ears, Nose, and Throat

Chest and Lungs

Heart

Blood Vessels

Breasts and Axillae

Abdomen

Female Genitalia

Male Genitalia

Anus, Rectum, and Prostate

Musculoskeletal System

Neurologic System

Sports Participation Evaluation

Putting it All Together

Emergency or Life-Threatening Situations

Filters

Exam 5: Documentation

The position on a clock, topographic notations, and anatomic landmarks:

The examiner's evaluation of a patient's mental status belongs in the:

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record?

The History and Interviewing Process

Cultural Competency

Examination Techniques and Equipment

Clinical Reasoning

Vital Signs and Pain Assessment

Mental Status

Growth, Measurement, and Nutrition

Skin, Hair, and Nails

Lymphatic System

Head and Neck

Eyes

Ears, Nose, and Throat

Chest and Lungs

Heart

Blood Vessels

Breasts and Axillae

Abdomen

Female Genitalia

Male Genitalia

Anus, Rectum, and Prostate

Musculoskeletal System

Neurologic System

Sports Participation Evaluation

Putting it All Together

Emergency or Life-Threatening Situations

Filters