©THEBRIGHTSTARS 2024
Module 1: Health History and
Documentation Exam Questions With
Correct Answers
Types of Medical Documentation (Notes) - answer✔✔Comprehensive History and Physical
Exam Note
Focused History and Physical Exam Note
SOAP Note
Progress Note
Transition of Care Note
Procedure Note
Types of Medical Documentation (Notes): Comprehensive History and Physical Exam Note -
answer✔✔-Need to know how to do all portions of this exam - includes a lot of things
-Will take you through everything
source of fundamental and personalized knowledge about the pt that strengthens the clinician-
patient relationship
-all the info about the pt, identifying info all the way through CC and HPI, PMH, Social Hx,
Exam, assessment/problem list, treatment plans/regular plans (sexual health, spiritual, etc) =
yearly physical - one time a year going through everything
Types of Medical Documentation (Notes): Focused History and Physical Exam Note -
answer✔✔happen in urgent care/ER/pt family practice/internal medicine and follow up; pt
seeking care for specific concerns (ex. cough, painful urination), a more limited interview
tailored to that specific problem
- use in places at Urgent care, ER's or if you are following up with pt (pt you already know if
PCP and peds) - pt comes in with a specific concern - show up 3 months down the road bc they
have a new complaint (hurt ankle, sore throat)
Types of Medical Documentation (Notes): SOAP Note - answer✔✔documentation: subjective,
objective, assessment, and plan - how the note is structured
, ©THEBRIGHTSTARS 2024
-for follow up info or exam - pt comes in and has hypertension and see if medications have been
helping - CC, HPI and brief review of system (doesn't include F/S hx)
Types of Medical Documentation (Notes): Progress Note - answer✔✔in patient/follow up visits -
addressing concern pt has - come back for a follow up visit
part of a medical record where healthcare professionals record details to document a patient's
clinical status or achievements during the course of a hospitalization or over the course of
outpatient care
- follow same format of SOAP - in patient notes - writing every day - add in a daily update as
whole hx isn't changing daily
Types of Medical Documentation (Notes): Transition of Care Note - answer✔✔pt needs to be
transitioned to different level of care ex. ICU to regular floor or from hospital to extended care
facility or DC summary that will be sent to PCP
- write when pt is transitioning level of care: pt is going out of the hospital (DC summary - note
sent to PCP/specialties), changing levels of care at the hospital - into or out of ICU - like SOAP
but also why they are able to move into or out of the hospital/ICU/hospital to extended care
facility/nursing home - person leaves your care you are writing a ___ Note - intake when they
come in and when they come out
Types of Medical Documentation (Notes): Procedure Note - answer✔✔note you write when you
do a procedure - what, why, and how
supplement to PN or History and Physical note - what procedure was done - what, why, how,
how you prepped, etc
Abbreviations - answer✔✔Acceptable abbreviations are defined by the organization
Be consistent
Not using at this point of time
Health History - answer✔✔Def: "structured framework for organizing patient information into
verbal or written form".
the pt's health story
focuses on essential information (what info do I need to address the particular situation of the
day ex. PCP may take several encounters, Urgent care- that particular concern of the day)
When it is comprehensive - can be very detailed - birth to early childhood to present day
Reasons do to a Health History - answer✔✔facilitates clinical reasoning
, ©THEBRIGHTSTARS 2024
give you opportunity to organize thoughts and concerns to come up with a plan for the pt (what
tests to order or not, what physical exam do I need to do, what labs, what dx do I need to
consider)
*Listen to the pt they will tell you what exactly is wrong with them
Comprehensive History - answer✔✔•Identifying information
•Source of history
•Chief Complaint/"Concern"
•History of Present Illness (what is happening right now (not the entire hx of the pt)
•Past Medical History
•Family History
•Personal and Social History
•Review of Symptoms
Comprehensive History: Identifying information - answer✔✔identifying data - pt's initials, age,
gender
- Date and Time - keep a running detailed note
- Identifying Data: pt name and date of birth
- Source of Information/Reliability - most pts will be their own source of info (they are awake,
alert and appropriate to give you this info) - others may have dementia or unconscious and can't,
have cognitive dysfunctions - document who is the source of information and how reliable they
are (pt can be a poor historian) - receive info from chart or other physicians - where this info
came from and how reliable this is
Comprehensive History: Source of history - answer✔✔usually the pt but can be a family
member, caregiver, or friend, or the clinical record
Subjective Data - answer✔✔Is what the patient tells you
includes symptoms and feelings, perceptions and concerns obtained from the clinical interview
usually verbal
ex. I think my heart is racing
Subjective Data: Documentation - answer✔✔Included in CC, HPI, and ROS
Use patient's own words and quotes as appropriate
Module 1: Health History and
Documentation Exam Questions With
Correct Answers
Types of Medical Documentation (Notes) - answer✔✔Comprehensive History and Physical
Exam Note
Focused History and Physical Exam Note
SOAP Note
Progress Note
Transition of Care Note
Procedure Note
Types of Medical Documentation (Notes): Comprehensive History and Physical Exam Note -
answer✔✔-Need to know how to do all portions of this exam - includes a lot of things
-Will take you through everything
source of fundamental and personalized knowledge about the pt that strengthens the clinician-
patient relationship
-all the info about the pt, identifying info all the way through CC and HPI, PMH, Social Hx,
Exam, assessment/problem list, treatment plans/regular plans (sexual health, spiritual, etc) =
yearly physical - one time a year going through everything
Types of Medical Documentation (Notes): Focused History and Physical Exam Note -
answer✔✔happen in urgent care/ER/pt family practice/internal medicine and follow up; pt
seeking care for specific concerns (ex. cough, painful urination), a more limited interview
tailored to that specific problem
- use in places at Urgent care, ER's or if you are following up with pt (pt you already know if
PCP and peds) - pt comes in with a specific concern - show up 3 months down the road bc they
have a new complaint (hurt ankle, sore throat)
Types of Medical Documentation (Notes): SOAP Note - answer✔✔documentation: subjective,
objective, assessment, and plan - how the note is structured
, ©THEBRIGHTSTARS 2024
-for follow up info or exam - pt comes in and has hypertension and see if medications have been
helping - CC, HPI and brief review of system (doesn't include F/S hx)
Types of Medical Documentation (Notes): Progress Note - answer✔✔in patient/follow up visits -
addressing concern pt has - come back for a follow up visit
part of a medical record where healthcare professionals record details to document a patient's
clinical status or achievements during the course of a hospitalization or over the course of
outpatient care
- follow same format of SOAP - in patient notes - writing every day - add in a daily update as
whole hx isn't changing daily
Types of Medical Documentation (Notes): Transition of Care Note - answer✔✔pt needs to be
transitioned to different level of care ex. ICU to regular floor or from hospital to extended care
facility or DC summary that will be sent to PCP
- write when pt is transitioning level of care: pt is going out of the hospital (DC summary - note
sent to PCP/specialties), changing levels of care at the hospital - into or out of ICU - like SOAP
but also why they are able to move into or out of the hospital/ICU/hospital to extended care
facility/nursing home - person leaves your care you are writing a ___ Note - intake when they
come in and when they come out
Types of Medical Documentation (Notes): Procedure Note - answer✔✔note you write when you
do a procedure - what, why, and how
supplement to PN or History and Physical note - what procedure was done - what, why, how,
how you prepped, etc
Abbreviations - answer✔✔Acceptable abbreviations are defined by the organization
Be consistent
Not using at this point of time
Health History - answer✔✔Def: "structured framework for organizing patient information into
verbal or written form".
the pt's health story
focuses on essential information (what info do I need to address the particular situation of the
day ex. PCP may take several encounters, Urgent care- that particular concern of the day)
When it is comprehensive - can be very detailed - birth to early childhood to present day
Reasons do to a Health History - answer✔✔facilitates clinical reasoning
, ©THEBRIGHTSTARS 2024
give you opportunity to organize thoughts and concerns to come up with a plan for the pt (what
tests to order or not, what physical exam do I need to do, what labs, what dx do I need to
consider)
*Listen to the pt they will tell you what exactly is wrong with them
Comprehensive History - answer✔✔•Identifying information
•Source of history
•Chief Complaint/"Concern"
•History of Present Illness (what is happening right now (not the entire hx of the pt)
•Past Medical History
•Family History
•Personal and Social History
•Review of Symptoms
Comprehensive History: Identifying information - answer✔✔identifying data - pt's initials, age,
gender
- Date and Time - keep a running detailed note
- Identifying Data: pt name and date of birth
- Source of Information/Reliability - most pts will be their own source of info (they are awake,
alert and appropriate to give you this info) - others may have dementia or unconscious and can't,
have cognitive dysfunctions - document who is the source of information and how reliable they
are (pt can be a poor historian) - receive info from chart or other physicians - where this info
came from and how reliable this is
Comprehensive History: Source of history - answer✔✔usually the pt but can be a family
member, caregiver, or friend, or the clinical record
Subjective Data - answer✔✔Is what the patient tells you
includes symptoms and feelings, perceptions and concerns obtained from the clinical interview
usually verbal
ex. I think my heart is racing
Subjective Data: Documentation - answer✔✔Included in CC, HPI, and ROS
Use patient's own words and quotes as appropriate
