Chapter 05: Documentation
Ball: Seidel’s Guide to Physical Examination, 9th Edition
MULTIPLE CHOICE
1. 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.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
2. 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.
DIF: Cognitive Level: Applying (Application)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
3. Which 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.
DIF: Cognitive Level: Understanding (Comprehension)
, OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
4. 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.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
5. 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.
DIF: Cognitive Level: Understanding (Comprehension)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
6. 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.
DIF: Cognitive Level: Applying (Application)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
7. Which is an example of a problem that requires recording on the patient’s problem list?
a. Common age variations
b. Expected findings
Ball: Seidel’s Guide to Physical Examination, 9th Edition
MULTIPLE CHOICE
1. 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.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
2. 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.
DIF: Cognitive Level: Applying (Application)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
3. Which 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.
DIF: Cognitive Level: Understanding (Comprehension)
, OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
4. 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.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
5. 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.
DIF: Cognitive Level: Understanding (Comprehension)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
6. 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.
DIF: Cognitive Level: Applying (Application)
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
7. Which is an example of a problem that requires recording on the patient’s problem list?
a. Common age variations
b. Expected findings
