Exam 4: Patient Assessment

Which medical record system has a standard format that makes it easy to read and audit?

Progress notes in the POMR include the use of SOAPE documentation.

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

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

The best method of ensuring that the patient understands a patient education intervention is to have the patient repeat back the details learned.

Providing patients with automatic reassurance when they express a concern is part of a therapeutic relationship.

Which of the following is a stage 3 requirement for Medicare and Medicaid EHR Incentive Program?

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?

Which of the following processes involved in active listening seeks to summarize or simplify the sender's thoughts and feelings or to resolve any confusion in the message?

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

__________ are subjective reports given by patients about how they feel with a particular health problem.

Which type of data collection is NOT associated with holistic care?

The medical assistant is responsible for documenting all of the following information except the

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

Helen Conrad,age 54,was recently diagnosed with epilepsy.She is very upset about the news.A therapeutic interaction might be

Identify the legal and ethical issues associated with the medical record.

If the medical assistant is caring for an aging patient who has difficulty hearing,he or she should ignore the patient and direct the interaction toward a family member.

Which of the following factors is likely to have the most influence on the accuracy and completeness of the information obtained from the patient during the medical history?

The __________ component of the medical history contains details about the patient's insurance,address,and date of birth.

When the medical assistant asks the patient about the duration of the symptoms,the question refers to the length of time the patient has had the symptoms.