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MCPHS Exam 2 - Patient Assessment: Questions And Complete Answers
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MCPHS Exam 2 - Patient Assessment: Questions And Complete Answers
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MCPHS Exam 2 - Patient Assessment: Questions AndComplete Answers
The medical record is a legal document, name 4 parties that are legally
allowed to view it. Right Ans - 1- Court - Medical Legal document
2- Communication tool between providers
4- Health care payment determinations (coding and billing)
5- Quality control and research (education)
What does CMS stand for? Right Ans - Centers for Medicare and Medicaid
Services - the nations
largest payer for healthcare services.
Why do you need to confirm accurateness of reported services and validate
site, necessity, appropriateness of services provided? Right Ans - audits /
fraud
Who cannot legally access a medical record? Right Ans - police and lawyers
The medical record establishes your _______________ as a health care provider
Right Ans - establishes your credibility as a health care provider*
Identify general principles of documentation include Right Ans - Brief
notes during exam
Record ASAP
Avoid abbreviations
Document observations only and what a patient tells you, not your personal
interpretations
Record expected and unexpected findings
Do not carry forward/ copy & paste
Why do you not carry forward/ copy & paste medical info? Right Ans - -Can
impact patient safety
-Can perpetuate erroneous or outdated information
-Can pose significant legal and regulatory challenges
What are the 4 types of notes? Right Ans - Problem Focused
Expanded Problem Focused
,Detailed
Comprehensive
Each type of NOTE includes some or all of the following elements (4) Right
Ans - 1- Chief complaint (CC)
2- History of present illness (HPI)
3- Review of systems (ROS)
4- Past, family, and/or social history (PFSH)
What is a problem focused note? Right Ans - a limited examination of the
affected body area or organ system. questions are directed at problem.
What is a Comprehensive note? Right Ans - a general multi-system
examination, or complete examination of a single organ system and other
symptomatic or related body area(s) or organ system(s).
When documenting a comprehensive note, which terms are used to describe
the level of service for:
History of Presenting Illness (HPI)
Review of Systems (ROS)
Past, Family, and/or Social HX (PFSH)
Type of History Right Ans - (HPI) Extended
(ROS) Complete
(PFSH)Complete
Type of History Comprehensive
What does SOAP stand for? Right Ans - Subjective
Objective
Assessment
Plan
Subjective means? Right Ans - What the patent tells you, what you can
see /hear
When is there an exception to not do a comprehensive SOAP note? Right
Ans - when a patient presents with an emergent need and initiating treatment
is a higher priority
When can you do a Focused note? Right Ans - -Established patients
,-Routine or urgent care visits
-Addresses focused concerns (ankle sprain, finger laceration)
What components go in the SUBJECTIVE part of a SOAP note? Right Ans -
Patient ID info (verify)
Source of info (usually patient)
CC (chief concern)
HPI in paragraph (OLDCARTS)
PMH
Social History (SODAHTIMESS)
Family History
ROS (if it makes more sense to put this directly after the HPI, no one will fault
you.)
What does OLDCARTS stand for? Right Ans - Onset
Location
Duration
Characteristics
Aggravating and Alleviating Factors
Radiation/ related symptoms
Timing
Severity
What components are in the PMH? Right Ans - PMH:
Adult
Childhood
Surgery
OBGYN
Psychiatric history
Health Maintenance/Vaccinations
If a patient is coming in for a check up, what should the CC read? Right Ans
- CC: yearly routine physical
Avoid using "checkup" or "no complaints"
First sentence of an HPI needs to document whats? Right Ans - identifying
and important information upfront "15 yr old male presents to ED via uber"
, How is the PMH different from a Problem List? Right Ans - PROBLEM LIST
is a running list of active, remote, or resolved medical complaints that the
patient has been evaluated for.
PMH will have further subdivisions that require detail detail detail and dates
Previous large scale diagnostic testing goes under which category of the SOAP
note? Right Ans - PMH, usually adult
"MRI C Spine July 2015 - normal MRI per radiology report"
where does this go? Right Ans - PMH, usually adult
Documents hx of resolved communicable diseases goes under which category
of the SOAP note? Right Ans - PMH, usually childhood
"resolved measles and chickenpox ages unknown. Treated for Pertussis
exposure age 13"
where does this go>? Right Ans - PMH, childhood
"Wisdom tooth extraction age 17 , oral surgery, Dr. Smiles, Manchester NH"
where does this go? Right Ans - PMH, surgical
no adverse effects to anesthesia/ no FHx
Where does this go?
what does FHx mean? Right Ans - PMH, surgical
means Family History
where does last normal menstrual cycle, methods of contraception go in the
SOAP note? Right Ans - PMH, OB gyn
sexual history can fit into which two sections of the SOAP note? Right Ans -
PMH, OB GFyn
or Social History
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