Chapter 05: The Patient Record [New title / focus!]
MULTIPLE CHOICE
1. Which pa of he info ma ion con ained in he pa ien eco d ma be ed in co ?
a. Subjective information only b. Objective information only c. Diagnostic information only d.
All information
ANS: D
An hing ha i en e ed in o a pa ien eco d, in pape o elec onic fo m, 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 M . S lo of
appe i e, i o ld be be e o: 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.
MULTIPLE CHOICE
1. Which pa of he info ma ion con ained in he pa ien eco d ma be ed in co ?
a. Subjective information only b. Objective information only c. Diagnostic information only d.
All information
ANS: D
An hing ha i en e ed in o a pa ien eco d, in pape o elec onic fo m, 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 M . S lo of
appe i e, i o ld be be e o: 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.
