Chapter 26: Recording Information

If information is purposely omitted from the record, you should:
a.
erase the notes that are not pertinent.
b.
accept that sometimes data are omitted.
c.
state in the record why the information was omitted.
d.
use correction fluid to cover the information.
ANS: C
Any deferred or omitted portion of the patient record requires proper documentation that documents this occurrence, along with a rationale for doing so. Erasures and use of correction fluid are inappropriate methods.

REF: p. 616

Which part of the information contained in the patient’s record may be used in court?
a.
Subjective information only
b.
Objective information only
c.
Diagnostic information only
d.
All information
ANS: D
Anything that is entered into a patient’s record, in paper or electronic form, is a legal document and can be used in court.

REF: p. 616

During the course of the interview, you should:
a.
take no notes of any kind.
b.
take brief written notes.
c.
take detailed written notes.
d.
repeat pertinent comments into a dictation devise.
ANS: B
During the interviewing process, it is important to maintain eye contact with the patient and to spend as little time as possible looking at your notes, so brief written notes are more practical. Later you can go back and formulate a well-versed history by linking all the pieces together.

REF: p. 616

Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S’s loss of appetite, it would be better to:
a.
defer or omit her comments.
b.
have her husband call you.
c.
quote her concerns verbatim.
d.
refer her for psychiatric treatment.
ANS: C
It is best to document what you observe and what is said by the patient rather than documenting your interpretation. Listening and quoting exactly what the patient says is the better rule to follow.

REF: p. 621

Subjective and symptomatic data are:
a.
documented with the physical examination findings.
b.
not mentioned in the legal chart.
c.
placed in the history section.
d.
recorded with the examination technique.
ANS: C
Subjective data, as well as symptomatic data, should be placed in the history section.

REF: p. 621

The quality of a symptom, such as pain, is subjective information that should be:
a.
deferred until the cause is determined.
b.
described in the history.
c.
placed in the past medical history section.
d.
placed in the history with objective data.
ANS: B
Information about pain is subjective and only the patient can rate the perceived severity. Pain, therefore, should be recorded in the history.

REF: p. 616

Which of the following is an effective adjunct to document the location of findings during the recording of the physical examination?
a.
Relationship to anatomic landmarks
b.
Computer graphics
c.
Comparison with other patients of same gender and size
d.
Comparison to previous examinations using light pen markings
ANS: A
Abnormal or normal findings are best described in relationship to universal topographic and anatomic landmarks.

REF: p. 618

The position on a clock, topographic notations, and anatomic landmarks:
a.
are methods for recording locations of findings.
b.
are used for noting disease progression.
c.
are ways for recording laboratory study results.
d.
should not be used in the legal record.
ANS: A
Descriptions of the locations of findings are universally referenced by using positions on a clock, topographic notations, or anatomic landmarks.

REF: p. 618

Regardless of the origin, discharge is described by noting:
a.
a grading scale of 0 to 4.
b.
color and consistency.
c.
demographic data and risk factors.
d.
associated symptoms in alphabetic order
ANS: B
Regardless of where the discharge originates, color and consistency determine whether it is an expected finding.

REF: p. 619

Drawing of stick figures is most useful to:
a.
compare findings in extremities.
b.
demonstrate radiation of pain.
c.
indicate consistency of lymph nodes.
d.
indicate mobility of masses.
ANS: A
Simple drawings, such as stick figures, are more practical illustrations for findings in extremities. Radiation of pain, consistency of lymph nodes, and mobility of masses would not be adequately described by such simple drawings.

REF: p. 619

Which of the following is an example of a problem that requires recording on the patient’s problem list?
a.
Common age variations
b.
Expected findings
c.
Problems needing further evaluation
d.
Minor variations
ANS: C
Any problem is worth noting on the patient problem list, even if the cause or significance is unknown. Common age variations, expected findings, and minor variations within normal limits should not be classified as a problem.

REF: p. 619

A problem may be defined as anything that will require:
a.
evaluation.
b.
medication.
c.
surgery.
d.
treatment.
ANS: A
The need for further evaluation or attention indicates a problem. If a problem is found, it does not necessarily warrant medication, surgery, or treatment.

REF: pp. 619-620

Differential diagnoses belong in the:
a.
history.
b.
physical examination.
c.
assessment.
d.
plan.
ANS: C
Differential diagnoses for problems that have not been diagnosed are placed in the assessment category for each problem. The differentials are prioritized, and contributing factors are identified.

REF: p. 620

When recording assessments during the construction of the problem-oriented medical record, the examiner should:
a.
combine all data into one assessment.
b.
create an assessment for each problem on the problem list.
c.
create an assessment for every abnormal physical finding.
d.
create an assessment for every symptom presented in the history.
ANS: B
Once the examiner has a list of problems constructed, an assessment is made for each unique problem.

REF: p. 620

Which of the following is not a component of the plan portion of the problem-oriented medical record?
a.
Diagnostics ordered
b.
Therapeutics
c.
Patient education
d.
Differential diagnosis
ANS: D
The differential diagnosis is part of the assessment phase.

REF: p. 620

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n):
a.
progress note.
b.
accident report.
c.
problem-oriented medical record.
d.
triage note.
ANS: A
A second visit with the clinician is always recorded on a progress note, noting any updates to the condition.

REF: p. 621

A detailed description of the symptoms related to the chief complaint is presented in the:
a.
history of present illness.
b.
differential diagnosis.
c.
assessment.
d.
general patient information section.
ANS: A
The signs and symptoms and historical data of the patient’s experience that led up to the chief complaint are placed in the history of present illness.

REF: p. 621

The effect of the chief complaint on the patient’s lifestyle is recorded in which section of the medical record?
a.
Chief complaint
b.
History of present illness
c.
Past medical history
d.
Social history
ANS: B
The effect of the patient’s complaint on current everyday lifestyle or work performance is recorded in the history of present illness.

REF: p. 621

The patient’s perceived disabilities and functional limitations are recorded in the:
a.
problem list.
b.
general patient information.
c.
social history.
d.
past medical history.
ANS: D
The past medical history contains information about the patient’s lifestyle as well as disabilities or functional limitations that alter activities of daily living.

REF: p. 622

The review of systems is a component of the:
a.
physical examination.
b.
health history.
c.
assessment.
d.
past medical-surgical history.
ANS: B
The review of systems relates health history according to physical systems and is presented just before the actual physical examination.

REF: pp. 621-622

Allergies to drugs and foods are generally listed in which section of the medical record?
a.
History of present illness
b.
Past medical history
c.
Social history
d.
Problem list
ANS: B
The past medical history section contains information such as allergies to drugs and foods and environmental allergies.

REF: p. 622

Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of this information is part of Ms. G’s _____ history.
a.
family
b.
past medical
c.
personal and social
d.
present problem
ANS: C
Information such as education and economic condition is part of the personal and social history.

REF: p. 622

Information recorded about an infant differs from that recorded about an adult, mainly because of the infant’s:
a.
attention span.
b.
developmental status.
c.
nutritional differences.
d.
source of information.
ANS: B
The organizational structure of an infant’s record is different because the infant’s current and future health are referenced in terms of developmental status.

REF: p. 626

In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?
a.
Family
b.
Past medical
c.
Personal and social
d.
Present problem
ANS: D
For the newborn, the focus of recorded information is the details of the mother’s pregnancy, gestational development, and events occurring since birth. These data are recorded in the present problem section of the history.

REF: p. 626

Which finding is unique to the documentation of a physical examination of an infant?
a.
Fontanel size
b.
Liver span
c.
Prostate size
d.
Thyroid position
ANS: A
The size and characteristic of the fontanel are unique and important in the assessment of an infant.

REF: p. 626

Eye examination of the newborn does not routinely include assessment of:
a.
the red reflex.
b.
the corneal reflex.
c.
object tracking.
d.
the fundus.
ANS: D
The fundus of the eye is not routinely assessed in a newborn.

REF: p. 626

Data relevant to the social history of older adults includes information on:
a.
family support systems.
b.
previous health care visits.
c.
over the counter medication intake.
d.
date of last cancer screening.
ANS: A
The social history of older adults includes community and family support systems.

REF: p. 628

A SOAP note is used in which type of recording system?
a.
Preventive care
b.
Problemoriented
c.
Systems review
d.
Traditional treatment
ANS: B
A SOAP note—subjective problem data, objective problem data, assessment, and plan— is a type of recording system that has a problem-oriented style.

REF: p. 620

The examiner’s evaluation of a patient’s mental status belongs in the:
a.
history of present illness.
b.
review of systems.
c.
physical examination.
d.
patient education.
ANS: C
Mental status assessment, including cognitive and emotional stability and speech and language, is part of the physical examination.

REF: p. 624

When recording physical findings, which data are recorded first for all systems?
a.
Inspection
b.
Percussion
c.
Palpation
d.
Auscultation
ANS: A
Physical assessment for all systems begins with inspection.

REF: p. 618

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?
a.
Brief SOAP note
b.
Comprehensive health history
c.
Progress note
d.
Referral note
ANS: A
Follow-up visits for problems identified in the POMR are recorded in the progress notes. Those visits not identified as problems are recorded using the SOAP format. Careful review of all SOAP notes on a regular basis will detect the emergence of a condition that explains the patient’s complaints; at that point, SOAP documentation is stopped

REF: p. 618

George Michaels, a 22-year-old patient, tells the nurse that he is here today to “check his allergies.” He has been having “green nasal discharge” for the last 72 hours. How would the nurse document his reason for seeking care?
a.
GM is a 22-year-old male here for “allergies.”
b.
GM came into the clinic complaining of green discharge for the past 72 hours.
c.
GM, a 22-year-old male, states that he has allergies and wants them checked.
d.
GM is a 22-year-old male here for having “green nasal discharge” for the past 72 hours.
ANS: D
Documentation of the chief complaint should always be done by using the patient’s own words in quotation marks.

REF: p. 616

When using the mnemonic OLDCARTS, the A stands for ______________________.
ANS:
aggravating and associated factors

The OLDCARTS mnemonic helps make sure that all characteristics of a problem are described in the history of present illness to ensure a comprehensive presentation. The order of recording these characteristics does not need to be consistent.

REF: p. 622