Quiz 2: Introduction to Health Records


D Explanation: Health records contain information crucial to patient care, are roadmaps to a patient's health history, and provide a clearer picture of the best route to take in future treatment of the patient.

A Explanation: The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the subjective part of the note.

B Explanation: Information such as the patient's physical exam, any laboratory findings, and imaging studies performed during the visit would be contained in the objective part of the diagnostic process.