Question: In charting, subjective data includes the ____.

Answer: patient's chief complaint

Question: The physician's diagnosis or impression of the patient's problem is the ____.

Answer: assessment

Question: Which of the following would you document under the plan of action?

Answer: Medications prescribed and tests to be done

Question: Which of the following is appropriate for conducting a successful interview?

Answer: Assist the patient to a private room and close the door

Question: Which of the following methods of collecting patient data requires more than a yes-or-no answer and encourages the patient to explain the situation?

Answer: Asking open-ended questions

Question: Mirroring means ____.

Answer: restating what the patient says in your own words

Question: "Where would you like to begin?" is an example of which method of collecting patient data?

Answer: Encouraging the patient to take the lead

Question: "You seem to be making progress, don't you agree?" is an example of which method of collecting patient data?

Answer: Asking leading questions

Question: Which of the following offers the patient little freedom to explain his answers and requires only yes-or-no answers?

Answer: Asking closed-ended questions

Question: Which of the following is characteristic of depression?

Answer: Symptoms include difficulty falling asleep, loss of appetite, and loss of energy.

Question: Which of the following commonly abused drugs are amphetamines/stimulants?

Answer: Dexedrine, Benzedrine, and methamphetamine

Question: Which of the following are common effects of LSD?

Answer: Grandiose feelings, hallucinations, mystical experiences, flashbacks

Question: Which of the following are other names for cocaine?

Answer: Coke, snow, crack

Question: Angel dust is also known as ____.

Answer: PCP

Question: The information in the patient's chart is ____.

Answer: a legal record of treatment rendered

Question: During a patient interview, you note signs of anxiety in the patient. You may be able to help the patient by ____.

Answer: allowing him to describe his feelings

Question: Which of these patient behaviors is a classic symptom of depression?

Answer: Profound sadness

Question: When charting, the need for ____ makes it essential that you use medical terminology and precise descriptions.conciseness

Answer: clarity

Question: Which of the following statements does not apply to the Patient's Bill of Rights (Patient Care Partnership)?

Answer: A privacy notice must be prominently posted within the hospital.

Question: Which of the following statements applies to HIPAA requirements?

Answer: A privacy notice must be prominently posted within the hospital.

Question: Which of the following does not apply to HIPAA requirements?

Answer: The medical assistant should be informed of available resources for resolving disputes.

Question: Which of the following applies to HIPAA requirements?

Answer: Healthcare facilities must inform patients, in writing, about disclosure of identifiable health information.

Question: Which of the following approaches allows you to determine the patient's knowledge of the situation and whether it is accurate?

Answer: Asking hypothetical questions

Question: Which of the following is an ineffective means of collecting data?

Answer: Probing for more information

Question: Asking the patient "Can you tell me more about your symptoms?" is which method of collecting patient data?

Answer: Asking open-ended questions

Question: The question "What would you do if you had chest pain?" represents which of the following methods of patient data collection?

Answer: Asking hypothetical questions

Question: Which method of patient data collection does the statement "So let me see if I understand; The pain only occurs at night." represent?

Answer: Verbalizing the implied

Question: Maintaining eye contact is a characteristic of which of these methods of data collection?

Answer: Focusing on the patient

Question: The question "Are you sure about that? It doesn't make sense to me." represents which method of collecting patient data?

Answer: Challenging the patient

Question: Which method of data collection does the question "What do you think is going on with you?" represent?

Answer: Encouraging the patient to evaluate his situation

Question: When you assume an open and relaxed body posture, you are demonstrating which data collection method?

Answer: Focusing on the patient

Question: The question "Where would you like to begin?" represents which method of data collection?

Answer: Encouraging the patient to take the lead

Question: An increased heart rate and confusion are effects of which of the following?

Answer: Ecstasy

Question: A decreased heart rate and blood pressure are effects of ____.

Answer: GHB

Question: Irene is a 26-year-old patient who is in the office for her annual physical examination. While you are interviewing her, she says she is feeling wonderful. She tells you she has been having mystical experiences and seems unusually aware of things around her. Which of the following drugs has she probably taken?

Answer: LSD

Question: Alternating euphoria and apprehension is an effect of ____.

Answer: stimulants

Question: John is a 15-year-old patient who plays on his high school basketball team. He says he is proud to be on the team's "first string." His mother brought him to the office because he is experiencing hearing loss and has frequent spasms in his legs. Which of the following are possible causes of these symptoms?

Answer: Paint thinner

Question: In response to your questions about social activities, Venira says she and her boyfriend have been dating for two years now, and they are very happy together. Something about her expression makes you think there might be more to the story, however. After a moment, she adds that her boyfriend, a high school football star, has been getting more and more aggressive and recently hit her during an argument. Which of the following might be the cause of this change in his behavior?

Answer: Anadrol

Question: Using SOAP charting, where would you document measurable information?

Answer: Objective data

Question: Which of the following information would you place in the "P" section when using SOAP charting?

Answer: Patient education

Question: Which of the following information would you place in the "S" section when using SOAP charting?

Answer: Patient's perceptions

Question: Which of the following would you place in the "A" section when using SOAP charting?

Answer: Physician's diagnosis

Question: Which method for maintaining notes on a patient chart is arranged according to who provided the information?

Answer: Conventional (source-oriented medical records)

Question: Which method for maintaining notes on a patient chart uses a combination of SOMR and POMR?

Answer: Computerized medical records

Question: ____ are used extensively by large clinics and practices and includes the database, problem list, treatment plan, and progress notes.

Answer: Problem-oriented medical records

Question: Which section of the health history form includes information about the health of the patient's family?

Answer: Family history

Question: The section of the health history form that contains information about when the problem started and what the patient has done to treat it is the ____.

Answer: history of present illness section

Question: Which section of the health history form includes questions about and examination (by the practitioner) of all body functions?

Answer: Review of systems

Question: Where on the health history form do you find the reason the patient came to visit the practitioner?

Answer: Chief complaint

Question: Important information about medications (including herbal and OTC) and allergies is found in which section of the health history form?

Answer: Past medical history

Question: Where on the health history form do you document information taken from the administrative sheet?

Answer: Personal data

Question: The ____ section of the health history form gives the practitioner information about exposure to hazardous substances, sexual practices, and chemical use habits.

Answer: social and occupational history

Question: In an effort to make a patient feel at ease, you should never____.

Answer: call a patient "honey" or "sweetie"

Question: Asking the patient "What do you think about this?" allows the patient to evaluate the situation and form an opinion. This is an example of ____.

Answer: reflection

Question: Jill Hanson is a 16-year-old patient who has come to the office complaining of lower abdominal pain. As you interview her, you notice that she seems to have difficulty concentrating on the conversation. She constantly looks toward the closed door of the exam room, and she asks you several times whether the doctor is "nice." Which of the following would you suspect as the reason for Jill's behavior?

Answer: Anxiety