Module 1: Interview, History, Physical Exam,
& Clinical Documentation Questions With
Correct Answers A+ Graded 2026/2027
Health History - correct answerMust actively involve the patient (and family, bystanders, or
other health care providers where appropriate) and must be individualized.
Patient interviews and documentation - correct answerPatient interviews and documentation
should provide the necessary documentation for payer reimbursement.
Providing a legal record of impressions, perceptions, and observable data.
Establishing an initial rapport and connection with the new patient.
If patients have special considerations/disabilities/pain what should you do? - correct answerIf
patients have special considerations/disabilities/pain, change your exam up to allow the least
movement possible, getting patient information while examining.
Focused/Problem-centered history - correct answerA focused assessment based on the chief
complaint, designed to elicit the required information to narrow down the differential diagnoses
to guide the assessment and plan for your patient.
SOAP Note - correct answerS: subjective
O: objective
A: assessment
P: plan
Subjective - correct answerChief complainta, History of present illness, Past medical history, Past
surgical history, Social history, Family history, Review of systems/symptoms
, Chief complaint - correct answerthe main reason for the patient's visit and in the patients own
words if possible
History of present illness - correct answerIncludes relevant information that tells the story of
the patient's chief complaint.
A detailed description of the symptoms and their progression.
Problem-Focused Exams should describe the attributes of a symptom (or use OLD-CARTS) to
guide your interview and documentation for the HPI.
Past Medical History/Past Surgical History - correct answerInformation about the patient's past
illnesses, surgeries, hospitalizations, allergies, and chronic conditions.
Social History - correct answerDetails about the patient's lifestyle, including occupation, habits
(like smoking or alcohol use), living arrangements, and level of physical activity.
Family History - correct answerHealth history of immediate family members, focusing on
illnesses that may be hereditary or relevant to the patient's current condition.
Review of Systems - correct answerA systematic inquiry about different organ systems to
identify any symptoms the patient may not have mentioned initially when collecting the
information about the history of present illness (HPI).
This component of the subjective assessment is essentially conducted by listing symptoms
where the patient would respond if they do or do not have that symptom (generally yes/no
questions).
It is organized and documented by SYSTEM (General, HEENT, Pulm, CV, GI, GU, etc).
Objective - correct answerPhyscial exam, diagnostic studies, vital signs
& Clinical Documentation Questions With
Correct Answers A+ Graded 2026/2027
Health History - correct answerMust actively involve the patient (and family, bystanders, or
other health care providers where appropriate) and must be individualized.
Patient interviews and documentation - correct answerPatient interviews and documentation
should provide the necessary documentation for payer reimbursement.
Providing a legal record of impressions, perceptions, and observable data.
Establishing an initial rapport and connection with the new patient.
If patients have special considerations/disabilities/pain what should you do? - correct answerIf
patients have special considerations/disabilities/pain, change your exam up to allow the least
movement possible, getting patient information while examining.
Focused/Problem-centered history - correct answerA focused assessment based on the chief
complaint, designed to elicit the required information to narrow down the differential diagnoses
to guide the assessment and plan for your patient.
SOAP Note - correct answerS: subjective
O: objective
A: assessment
P: plan
Subjective - correct answerChief complainta, History of present illness, Past medical history, Past
surgical history, Social history, Family history, Review of systems/symptoms
, Chief complaint - correct answerthe main reason for the patient's visit and in the patients own
words if possible
History of present illness - correct answerIncludes relevant information that tells the story of
the patient's chief complaint.
A detailed description of the symptoms and their progression.
Problem-Focused Exams should describe the attributes of a symptom (or use OLD-CARTS) to
guide your interview and documentation for the HPI.
Past Medical History/Past Surgical History - correct answerInformation about the patient's past
illnesses, surgeries, hospitalizations, allergies, and chronic conditions.
Social History - correct answerDetails about the patient's lifestyle, including occupation, habits
(like smoking or alcohol use), living arrangements, and level of physical activity.
Family History - correct answerHealth history of immediate family members, focusing on
illnesses that may be hereditary or relevant to the patient's current condition.
Review of Systems - correct answerA systematic inquiry about different organ systems to
identify any symptoms the patient may not have mentioned initially when collecting the
information about the history of present illness (HPI).
This component of the subjective assessment is essentially conducted by listing symptoms
where the patient would respond if they do or do not have that symptom (generally yes/no
questions).
It is organized and documented by SYSTEM (General, HEENT, Pulm, CV, GI, GU, etc).
Objective - correct answerPhyscial exam, diagnostic studies, vital signs
