C HAPTER 05: D OCUMENTATION
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 hou se 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
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 hou se 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
