Question 1

Which of the following is a benefit of CPOE?

Accepted Answer

A)   The results of a test are instantly received.
B)   The patient receives his/her test results at the same time as the provider.
C)   Clinical decision support is possible through CPOE.
D)   Using CPOE is less costly for the patient. C

Question 2

A patient with knee pain has been using pain patches to alleviate the pain; she has been using the kind that are left on the area for several hours. Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI).

Accepted Answer

A)   location
B)   timing
C)   severity
D)   modifying factors D

Question 3

In a hospital setting, what document is the equivalent of the assessment and plan that is collected as part of a SOAP note in an outpatient record?

Accepted Answer

A)   history and physical
B)   discharge summary
C)   progress note
D)   procedure note B

Question 4

Which of the following professionals would not perform a physical examination (PE)?

Accepted Answer

A)   medical assistant
B)   physician's assistant
C)   nurse midwife
D)   nurse practitioner

Question 5

Explain the difference between voice recognition and speech recognition technology. Why would one be preferred over the other by a care provider?

Accepted Answer

The answer of Explain the difference between voice recognition and...

Question 6

The SOAP documentation format is most commonly used in which healthcare setting?

Accepted Answer

A)   hospital inpatient
B)   physician's office
C)   hospital emergency department
D)   outpatient diagnostic department

Question 7

A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as

Accepted Answer

A)   electronic health records.
B)   computerized physician order entry.
C)   electronic prescribing.
D)   orders requisition.

Question 8

The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?

Accepted Answer

A)   musculoskeletal
B)   gastrointestinal
C)   neurologic
D)   constitutional

Question 9

The fact that a patient has taken an over-the-counter medication and received relief of his pain is known as what in relation to the subjective documentation found in this patient's chart?

Accepted Answer

The answer of The fact that a patient has taken...

Question 10

What is required in order for computerized physician order entry to occur between different healthcare facilities?

Accepted Answer

The answer of What is required in order for computerized...

Question 11

The extent of a physical exam will depend largely on the reason for the patient's visit, which is otherwise known as what?

Accepted Answer

The answer of The extent of a physical exam will...

Question 12

What information is considered to be part of the review of systems (ROS)?

Accepted Answer

The answer of What information is considered to be part...

Question 13

Meaningful Use guidelines require the keeping of an up-to-date

Accepted Answer

A)   dictation system.
B)   chart note.
C)   problem list.
D)   past medical history.

Question 14

In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital, a/an ____________________ must exist between the two computer systems.

Accepted Answer

A)   cable
B)   interface
C)   internet
D)   firewall

Question 15

Explain why a care provider's dictated and transcribed report would be more beneficial than a handwritten note.

Accepted Answer

The answer of Explain why a care provider's dictated and...

Question 16

What were the physical exam findings from the physical exam performed on Patti Wolfe?

Accepted Answer

The answer of What were the physical exam findings from...

Question 17

Of the following, which is a benefit of ePrescribing?

Accepted Answer

A)   The patient's demographic and insurance information is sent to the pharmacy from the office.
B)   There is less chance of medication errors being made.
C)   It is less expensive for the patient.
D)   Care providers and pharmacists are alerted to possible food/drug or drug/drug interactions.

Question 18

LaRhonda Howard is seen today by Dr. Bilkins for a chief complaint of recurrent abdominal pain and loss of appetite. Robert Drew is seen today by Dr. Bilkins for a chief complaint of follow-up for his poison ivy, which he was treated for last week. Which of these patients is likely to have a more extensive physical exam?

Accepted Answer

The answer of LaRhonda Howard is seen today by Dr....

Question 19

Tiffany Randall is seen by her physician after falling off a piece of playground equipment. She has a laceration on her chin. This is part of which element of the history of present illness?

Accepted Answer

The answer of Tiffany Randall is seen by her physician...

Question 20

Dr. Schultz has just examined Natalia Shrier who had come to see him because she has been having increasing problems with gastroesophageal reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to avoid eating within three hours of going to bed, to raise the head of her bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's instructions are part of which element in a SOAP note?

Accepted Answer

A)   Subjective
B)   Objective
C)   Assessment
D)   Plan

Exam 5: Content of the Health Recordthe Care Providers Responsibility