NURS 6512 Week 3 Quiz Question and Answers, Walden University.

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NURS 65112N Week 3 Quiz 1. If information is purposefully omitted from the record, you should 2. Which part of the information contained in the patient’s record may be used in court? 3. During th... e course of the interview, you should 4. 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 Ms. S’s loss of appetite, it would be better to 5. Subjective and symptomatic data are 6. The quality of a symptom, such as pain, is subjective information that should be 7. Which of the following is an effective adjunct to document location of findings during recording of physical examinations? 8. The position on a clock, topographic notations, and anatomic landmarks 9. Regardless of the orifice, discharge is described by noting 10. Drawing of stick figures is most useful to 11. Which of the following is an example of a problem requiring recording on the patient’s problem list? 12. A problem may be defined as anything that will require 13. Differential diagnoses belong in the 14. When recording assessments during the construction of the problem-oriented medical record, the examiner should 15. Which of the following is not a characteristic of the plan portion of the problem-oriented medical record? 16. Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n) 17. A detailed description of the symptoms related to the chief complaint is presented in the 18. The effect of the chief concern on the patient’s lifestyle is recorded in which section of the medical record? 19. The patient’s perceived disabilities and functional limitations are recorded in thepast medical history. 20. The review of systems is a component of the 21. Allergies to drugs and foods are generally listed in which section of the medical record? 22. Ms. G is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G’s _____ history. 23. Objective data are usually recorded 24. Information recorded about an infant differs from that of an adult, mainly because of the infant’s 25. In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data? 26. What finding is unique to the documentation of a physical examination of an infant? 27. Data relevant to the social history of older adults include information on 28. A SOAP note is used in which type of recording system? 29. The examiner’s evaluation of a patient’s mental status belongs in the 30. When recording physical findings, which data are recorded first for all systems? 31. Regarding another provider’s documented work, it 32. Which of the following is true regarding the use of “copy and paste, carry forward” (CPCF) in an electronic medical record? 33. The OLDCHARTS mnemonic is a way of documenting which of the following? [Show More]

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