Exam 28: Patient Assessment

__________ data include the patient's blood pressure, TPR, and weight.

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

Which of the following is not true of holistic patient care?

Lois Anderson was recently diagnosed with a functional disorder of the colon.Which of the following is true about her condition?

Describe the four sections of the POMR.

The physician's decision to refer a patient to a dietician is documented under the assessment category of SOAP records.

The SOMR begins with a list of the patient's health problems.

Why would you take a patient's vital signs at both the beginning and end of the office visit for a physical examination?

The physician's initial impression of what is wrong with the patient is called the __________ diagnosis.

It is important for the medical assistant to keep arms and legs crossed during an interview to communicate authority to the patient.

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

The section of the medical history that helps uncover existing or potential health problems is called the:

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

Which of the following includes childhood diseases?

Giving advice when it is requested by a patient is an effective way of displaying concern.

__________ is an attempt by the patient to hide a negative feeling he or she believes is unacceptable by doing the exact opposite.

During a physical examination the patient reports problems with speech and balance.These signs indicate a problem with which system?

Your office manager asks whether you know anything about defense mechanisms that patients might display if they are anxious.Summarize four defense mechanisms and provide an example of each.

While you are taking the medical history of a new patient, the patient mentions having occasional headaches that are quite painful.What is the best way for you to proceed with the interview?

Give a minimum of four rules that must be followed when documenting in a patient's record.