Complete Solutions
Demographic Information Correct Answers Identifiers: name,
address, phone number, gender, age
How many methods of ID should you use, and what should they
be? Correct Answers Two, name and date of birth
Chief Complaint (CC) Correct Answers main reason for the
visit
Subjective symptoms Correct Answers patients own
words/feelings that are not measure
- pain, itching
How do you record subjective symptoms? Correct Answers use
quotation marks
Objective symptoms Correct Answers can be measured and
observed
- past medical history, vital signs
medical reconsiliation Correct Answers compares patient list to
medical record at every visit, updates allergies
administrative information Correct Answers patient
information/demographic, financial insurance information,
correspondance
, medical history Correct Answers past illnesses, surgery,
injuries
family history Correct Answers illness/disease in immediate
family
social history Correct Answers diet, exercise, smoking/drugs,
alcohol, habits
occupational history Correct Answers employment
hazars/exposures
screening/wellness assessments may include Correct Answers -
alcohol, tobacco, caffeine, drugs, substance intake
- sexual practices
- diet and exercise
- occupational/employment history
What do you do if a patient declines to answer questions?
Correct Answers Encourage them, but if they refuse document
"patient declined to answer"
Patient mental health questionnaire - 2 (PHQ-2) Correct
Answers patients frequency of depressed mood over two weeks
Patient mental health questionnaire - 9 (PHQ-9) Correct
Answers if PHQ-2 answers reflect positive response, asks
additional questions
common depression symptoms Correct Answers - difficulty
going to/staying asleep