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Patient Care Exam Questions And Accurate Answers
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Patient Care Exam Questions And Accurate AnswersPersonal data-Answer information obtained from an administrative sheet and included
basic data such as patient's name, social security number and birth date.
Chief complaint-Answer (CC) is the reason the person came to the visit
History of present illness-Answer detailed information about the chief complaint,
including when the problem started and what the patient has done treat the problem.
Past medical history AbdAnswer includes all health problems both present and past
including major illnesses and surgery.
Family history AbdAnswer information about health of patient's family members. Many
times the family history can help lead a provider to the cause of a current medical
problem.
Social and occupational history - Answer marital status, sexual behaviours and
orientation, occupations, hobbies, and use of chemical substances- all aid to identify
patient's risk of diseases.
C's in Charting - Client's words - Answer patient's own phrasing must be recorded
exactly
Clarity - Answer use exact medical terminology
Completeness - Answer the chart must have all relevant information
Conciseness - Answer abbreviations use when possible, saves time and space
, Chronological order - Date all entries
Confidentiality - Protect patient's privacy.
Questions to ask when making a pain assessment - When did pain start; Where is the
pain; How often do you feel the pain; Does anything you do kessen the pain; Describe
the pain
You suspect a patient is being abused - Answer He/She has bruises all over their body.
The explanation given regarding those bruises is weak.
patient's medical record should have these documentations in each patient's medical
record: - Answer Patient registration form; Patient medical history; Physical exam
results; Lab and test results; copies of RX's and refill request; DX and treatment plan;
progress note, phone calls, consent forms
Narrative style charting - When physicians dictate notes about patient care then have
those notes transcribed and placed in the patient's files
SOAP note - Is an acronym for subjective, objective, assessment, and plan.
Problem-oriented medical record charting - POMR, is a method of tracking the patient's
problems during the time they are receiving medical care
Progress notes - Answer are daily chart notes which are used to record any information
that pertains to the various stages of a patient's condition
Normal ranges for the average healthy adult vital signs - Blood Pressure - Answer
normal BP is less than 120 (Diastolic) and less than 80 (systolic)
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