Question 1

The _______ medical history includes important information about medications and allergies.

Accepted Answer

The answer of The _______ medical history includes important information...

Question 2

When using the PQRST interview technique, the S stands for _________.

Accepted Answer

The answer of When using the PQRST interview technique, the...

Question 3

The ________ is the reason the patient came to visit the practitioner. It should be short and specific and should cover subjective and/or objective data.

Accepted Answer

The answer of The ________ is the reason the patient...

Question 4

The patient's name, Social Security number, and birth date are documented in the _______ data section of the health history form.

Accepted Answer

The answer of The patient's name, Social Security number, and...

Question 5

The ________ interview technique will help you remember the types of questions that are appropriate for the patient's condition.

Accepted Answer

The answer of The ________ interview technique will help you...

Question 6

The practitioner decides that the patient needs blood and urine tests. The practitioner will document this in the medical record under the _______ of action section in the SOAP format.

Accepted Answer

The answer of The practitioner decides that the patient needs...

Question 7

Information is arranged according to who provided the information in _______ or source-oriented medical records.

Accepted Answer

The answer of Information is arranged according to who provided...

Question 8

The use of alcohol, tobacco, recreational drugs, or other chemical substances is documented in the _______ history.

Accepted Answer

The answer of The use of alcohol, tobacco, recreational drugs,...

Question 9

The practitioner's diagnosis or impression of the patient's problem is documented in the _______ section of the SOAP format chart notes.

Accepted Answer

The answer of The practitioner's diagnosis or impression of the...

Question 10

The Joint Commission (TJC) issued a "Do Not Use" list of ________, acronyms, and symbols that should not be used in an effort to reduce medical errors.

Accepted Answer

The answer of The Joint Commission (TJC) issued a "Do...

Question 11

The Joint Commission (TJC) and the ______________ (ISMP) are two organizations whose mission includes promotion of patient safety by publishing the official "Do Not Use" list of abbreviations in an effort to reduce medical errors.

Accepted Answer

The answer of The Joint Commission (TJC) and the ______________...

Question 12

Conditions or problems are identified by a number throughout the record until the problem is resolved in _______ medical records.

Accepted Answer

The answer of Conditions or problems are identified by a...

Question 13

The history of ________ illness includes detailed information about the chief complaint, including when the problem started and what the patient has done to treat the problem.

Accepted Answer

The answer of The history of ________ illness includes detailed...

Question 14

Many offices use a variation of the _______ note to document routine follow-ups of established patients with ongoing conditions such as hypertension or arthritis.

Accepted Answer

The answer of Many offices use a variation of the...

Question 15

When an office uses _______ medical records, the records are accessible at any time and combine SOMR and POMR methods.

Accepted Answer

The answer of When an office uses _______ medical records,...

Question 16

In which year did enforcement of the HIPAA act, dealing with patient's rights, begin with penalties of up to $250,000 in fines and 10 years in jail?
A) 1992
B) 1998
C) 2001
D) 2003
E) 2005

Accepted Answer

The enforcement of the Health Insurance Portability and Accountability Act (HIPAA) with penalties began in 2003.

Quiz 36: Patient Interview and History