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Chapter 2: Introduction to Health Records

front 1 Chapter 2 Introduction to Health Records	back 1 no data
front 2 Chapter 2.1 The SOAP Method	back 2 no data
front 3 Chapter 2.1 The SOAP Method	back 3 no data
front 4 Learning Outcome 2.1 Exercises: Exercise 1.	back 4 1. c 2. a 3. d 4. a 5. c 6. c 7. a

front 5 Learning Outcome 2.1 Exercises: Exercise 2.	back 5 1. c 2. d 3. a 4. b
front 6 Learning Outcome 2.1 Exercises: Exercise 3, 4.	back 6 no data
front 7 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words	back 7 no data
front 8 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Subjective	back 8 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Subjective: General Subjective Terms Table

front 9 Learning Outcome 2.2 Exercises: Exercise 1, 2.	back 9 no data
front 10 Learning Outcome 2.2 Exercises: Exercise 3, 4.	back 10 no data
front 11 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Objective	back 11 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Objective: General Objective Terms Table
front 12 Learning Outcome 2.2 Exercises: Exercise 6, 7, 8.	back 12 no data

front 13 Learning Outcome 2.2 Exercises: Exercise 9, 10.	back 13 no data
front 14 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Assessment	back 14 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Assessment: General Assessment Terms Table
front 15 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Assessment: Public Health Table	back 15 no data
front 16 Learning Outcome 2.2 Exercises: Exercise 11, 12.	back 16 no data

front 17 Learning Outcome 2.2 Exercises: Exercise 13.	back 17 no data
front 18 Learning Outcome 2.2 Exercises: Exercise 14.	back 18 no data
front 19 Learning Outcome 2.2 Exercises: Exercise 15.	back 19 no data
front 20 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Plan	back 20 Chapter 2.2 Common Terms in Medicine Your Future Second-Nature Words - Plan: General Plan Terms Table & Public Health Table

front 21 Learning Outcome 2.2 Exercises: Exercise 16, 17.	back 21 no data
front 22 Learning Outcome 2.2 Exercises: Exercise 18, 19.	back 22 no data
front 23 Chapter 2.2 Common Terms in Medicine Body Planes and Orientation	back 23 no data
front 24 Chapter 2.2 Common Terms in Medicine Body Planes and Orientation Opposites Table: Part 1.	back 24 Chapter 2.2 Common Terms in Medicine Body Planes and Orientation Opposites Table: Part 2.

front 25 Chapter 2.2 Common Terms in Medicine Body Planes and Orientation Opposites Table: Part 3.	back 25 Chapter 2.2 Common Terms in Medicine Body Planes and Orientation Opposites Table: Part 4.
front 26 Chapter 2.2 Common Terms in Medicine Body Planes and Orientation Body Planes Table	back 26
front 27 Learning Outcome 2.2 Exercises: Exercise 20, 21.	back 27 no data
front 28 Learning Outcome 2.2 Exercises: Exercise 22, 23.	back 28 no data

front 29 Learning Outcome 2.2 Exercises: Exercise 24.	back 29 no data
front 30 Chapter 2.2 Common Terms in Medicine Health Professionals	back 30 no data
front 31 Chapter 2.2 Common Terms in Medicine Health Professionals Health Professions Table: Part 1.	back 31 Chapter 2.2 Common Terms in Medicine Health Professionals Health Professions Table: Part 2.
front 32 Learning Outcome 2.2 Exercises: Exercise 25.	back 32 no data

front 33 Learning Outcome 2.2 Exercises: Exercise 26, 27.	back 33 no data
front 34 Chapter 2.3 Common Terms in Medicine Types of Health Records	back 34 Chapter 2.3 Common Terms in Medicine Types of Health Records Sections of a Health Record Table
front 35 Chapter 2.3 Common Terms in Medicine Example Note #1: Clinic Note	back 35 Chapter 2.3 Common Terms in Medicine Example Note #1: Clinic Note Example
front 36 Chapter 2.3 Common Terms in Medicine Example Note #2: Consult Note	back 36 Chapter 2.3 Common Terms in Medicine Example Note #2: Consult Note Example

front 37 Chapter 2.3 Common Terms in Medicine Example Note #3: Emergency Department Note	back 37 Chapter 2.3 Common Terms in Medicine Example Note #3: Emergency Department Note Example
front 38 Chapter 2.3 Common Terms in Medicine Example Note #4: Admission Summary	back 38 Chapter 2.3 Common Terms in Medicine Example Note #4: Admission Summary Example
front 39 Chapter 2.3 Common Terms in Medicine Example Note #5: Discharge Summary	back 39 Chapter 2.3 Common Terms in Medicine Example Note #5: Discharge Summary Example
front 40 Chapter 2.3 Common Terms in Medicine Example Note #6: Operative Report	back 40 Chapter 2.3 Common Terms in Medicine Example Note #6: Operative Report Example

front 41 Chapter 2.3 Common Terms in Medicine Example Note #7: Daily Hospital Note/Progress Note	back 41 Chapter 2.3 Common Terms in Medicine Example Note #7: Daily Hospital Note/Progress Note Example
front 42 Chapter 2.3 Common Terms in Medicine Example Note #8: Radiology Report	back 42 Chapter 2.3 Common Terms in Medicine Example Note #8: Radiology Report Example
front 43 Chapter 2.3 Common Terms in Medicine Example Note #9: Pathology Report	back 43 Chapter 2.3 Common Terms in Medicine Example Note #9: Pathology Report Example
front 44 Chapter 2.3 Common Terms in Medicine Example Note #10: Prescription	back 44 Chapter 2.3 Common Terms in Medicine Example Note #10: Prescription Example

front 45 Chapter 2.3 Common Terms in Medicine Summary of Health Records Table: Part 1.	back 45 Chapter 2.3 Common Terms in Medicine Summary of Health Records Table: Part 2.
front 46 Learning Outcome 2.3 Exercises: Exercise 1, 2.	back 46 no data
front 47 Learning Outcome 2.3 Exercises: Exercise 3.	back 47
front 48 Learning Outcome 2.3 Exercises: Exercise 4.	back 48 no data

front 49 Learning Outcome 2.3 Exercises: Exercise 5.	back 49
front 50 Learning Outcome 2.3 Exercises: Exercise 6.	back 50
front 51 Learning Outcome 2.3 Exercises: Exercise 7.	back 51
front 52 Learning Outcome 2.3 Exercises: Exercise 7 Part 2.	back 52 no data

front 53 Learning Outcome 2.3 Exercises: Exercise 8.	back 53
front 54 Chapter 2.4 Abbreviations Abbreviations Associated with Health Care Facilities	back 54 Chapter 2.4 Abbreviations Abbreviations Associated with Health Care Facilities Health Care Facility Abbreviations Table
front 55 Learning Outcome 2.4 Exercises: Exercise 1.	back 55 no data
front 56 Learning Outcome 2.4 Exercises: Exercise 2, 3.	back 56 no data

front 57 Chapter 2.4 Abbreviations Abbreviations Associated with Patient Care Symbols Table	back 57 Chapter 2.4 Abbreviations Abbreviations Associated with Patient Care Abbreviations Common on Health Records Table
front 58 Chapter 2.4 Abbreviations Abbreviations Associated with Patient Care Abbreviations used for Symptoms or Exam Findings Table	back 58 Chapter 2.4 Abbreviations Abbreviations Associated with Patient Care Abbreviations Associated with Orders and Administering Medicine Table
front 59 Learning Outcome 2.4 Exercises: Exercise 4.	back 59 no data
front 60 Learning Outcome 2.4 Exercises: Exercise 5.	back 60 no data

front 61 Learning Outcome 2.4 Exercises: Exercise 6.	back 61 no data
front 62 Learning Outcome 2.4 Exercises: Exercise 7.	back 62 no data
front 63 Chapter 2.4 Abbreviations Timing- and Frequency-Based Abbreviations	back 63 Chapter 2.4 Abbreviations Timing- and Frequency-Based Abbreviations Timing Abbreviations Table
front 64 Learning Outcome 2.4 Exercises: Exercise 8, 9.	back 64 no data

front 65 Learning Outcome 2.4 Exercises: Exercise 10.	back 65 no data
front 66 Chapter 2.5 Electronic Health Records Clinic Note	back 66 Chapter 2.5 Electronic Health Records Clinic Note Clinic Note Example
front 67 Learning Outcome 2.5 Exercises: Exercise 1, 2, 3.	back 67 no data
front 68 Learning Outcome 2.5 Exercises: Exercise 4.	back 68 no data

front 69 Chapter 2.5 Electronic Health Records Consult Note Consult Note Sample Health Record (goes with Exercise 5)	back 69 no data
front 70 Learning Outcome 2.5 Exercises: Exercise 5.	back 70 no data
front 71 Chapter 2.5 Electronic Health Records Emergency Department Note Emergency Department Note Sample Health Record (goes with Exercise 7)	back 71 no data
front 72 Learning Outcome 2.5 Exercises: Exercise 6.	back 72 no data

front 73 Learning Outcome 2.5 Exercises: Exercise 7, 8.	back 73 no data
front 74 Chapter 2.5 Electronic Health Records Admission Note Admission Note Sample Health Record (goes with Exercise 10)	back 74 no data
front 75 Learning Outcome 2.5 Exercises: Exercise 9, 10.	back 75 no data
front 76 Learning Outcome 2.5 Exercises: Exercise 11.	back 76 no data

front 77 Learning Outcome 2.5 Exercises: Exercise 12.	back 77 no data
front 78 Learning Outcome 2.5 Exercises: Exercise 13.	back 78 no data
front 79 Chapter 2.5 Electronic Health Records Discharge Summary Discharge Summary Sample Health Record (goes with Exercise 14)	back 79
front 80 Learning Outcome 2.5 Exercises: Exercise 14.	back 80 no data

front 81 Learning Outcome 2.5 Exercises: Exercise 15, 16.	back 81 no data
front 82 Learning Outcome 2.5 Exercises: Exercise 17.	back 82 no data
front 83 Chapter 2.5 Electronic Health Records Operative Report Operative Report Sample Health Record (goes with Exercise 18)	back 83 no data
front 84 Learning Outcome 2.5 Exercises: Exercise 18.	back 84 no data

front 85 Chapter 2.5 Electronic Health Records Daily Hospital Note/Progress Note Operative Report Sample Health Record (goes with Exercise 19)	back 85 no data
front 86 Learning Outcome 2.5 Exercises: Exercise 19, 20.	back 86 no data
front 87 Learning Outcome 2.5 Exercises: Exercise 21.	back 87 no data
front 88 Chapter 2.5 Electronic Health Records Radiology Report Radiology Report Sample Health Record (goes with Exercise 22)	back 88 no data

front 89 Learning Outcome 2.5 Exercises: Exercise 22.	back 89
front 90 Chapter 2.5 Electronic Health Records Pathology Report Pathology Report Sample Health Record (goes with Exercise 23)	back 90 no data
front 91 Learning Outcome 2.5 Exercises: Exercise 23.	back 91 no data
front 92 Chapter 2.5 Electronic Health Records Prescription Prescription Example	back 92 no data

front 93 Learning Outcome 2.5 Exercises: Exercise 24.	back 93 no data
front 94 Learning Outcome 2.5 Exercises: Exercise 25.	back 94 no data
front 95 Select all that apply Which of the following would be in a patient's medical record? Multiple select question. Previous illnesses Grocery list Medications Treatments to the patient	back 95 Previous illnesses Medications Treatments to the patient
front 96 Data compiled through laboratory findings is considered ______. Multiple choice question. Plan Subjective Assessment Objective	back 96 Objective

front 97 Select all that apply List items that would be included in the Subjective section of a health record. Multiple select question. Timing of the problem Current medications Reason for the visit Patient's Plan of Care	back 97 Timing of the problem Current medications Reason for the visit
front 98 Which of the following would be included in the Objective part of the SOAP method? Multiple choice question. Treatment plan Patient's description Tests Prescriptions	back 98 Tests
front 99 Which of the following terms would be used to describe "assessment"? Multiple choice question. Degeneration Diagnosis Impression Benign Malignant	back 99 Impression
front 100 What is the abbreviation for "Electronic Health Record"? Multiple choice question. EMR EHR CMS SOAP	back 100 EHR

front 101 What happened to the patient at the end of the visit is Multiple choice question. disposition. palliative. prophylaxis. observation.	back 101 disposition.
front 102 Forming a logical analysis is in the ______ part of the SOAP method.	back 102 assessment
front 103 Match the different types of planes term to the definition.	back 103
front 104 The ______ section of a health record tells the patient's story of their health issues. Multiple choice question. assessment objective subjective plan	back 104 subjective

front 105 Select all that apply Which of the following terms are used to identify the back? Multiple select question. Posterior Dorsal Ventral Anterior	back 105 Posterior Dorsal
front 106 In the SOAP method, the ______ part of a health record tells about the data collected during the visit to the doctor.	back 106 objective
front 107 Drag and drop the definitions against the corresponding terms.	back 107
front 108 Match each general assessment term with the correct definition.	back 108

front 109 Match each general plan term with the correct definition.	back 109
front 110 Which of the following describes the supine position? Multiple choice question. Toward the bottom Lying down on back Out to the side Lying down on belly	back 110 Lying down on back
front 111 Which position is standing facing forward, arms at the side with the palms forward? Multiple choice question. Supine Prone Anatomic Distal	back 111 Anatomic
front 112 Which of the following terms describes the palm of the hand? Multiple choice question. Unilateral Palmar Plantar Dorsal	back 112 Palmar

front 113 Select all that apply Which of the following terms are used to identify the front? Multiple select question. Antral Anterior Ventral Superior Dorsal	back 113 Antral Anterior Ventral
front 114 The body plane that divides the body in slices right to left is Multiple choice question. transverse. frontal. sagittal. coronal.	back 114 sagittal.
front 115 The term ______ describes the term "the front" in body positioning.	back 115 Blank 1: anterior, ventral, or antral
front 116 Which of the following is a specially trained in treating patients respiratory issues under the guidance of a health care provider. Multiple choice question. Occupational Therapist Respiratory Therapist Physician Assistant Dietitian	back 116 Respiratory Therapist

front 117 Match the terminology for assessment terms with the correct definition.	back 117
front 118 Which of the following health care professionals specialize in the removal of blood from the body? Multiple choice question. Transcriptionist Patient service coordinator Ultrasonagrapher Phlebotomist	back 118 Phlebotomist
front 119 Which of the following describes the prone position? Multiple choice question. Toward the bottom Lying down on back Lying down on belly Out to the side	back 119 Lying down on belly
front 120 Select the color coding to the section of the SOAP method.	back 120

front 121 The sole of the foot is called ______.	back 121 plantar
front 122 Which of the following is the documentation method used for charting in the medical record? Multiple choice question. ABN EOB SOAP HHS	back 122 SOAP
front 123 Match the different types of body planes to their definition.	back 123
front 124 What type of documentation format is used for consultation notes? Multiple choice question. RA MSP EOB SOAP	back 124 SOAP

front 125 Match the health care professional with the job description.	back 125
front 126 Select all that apply What type of information is recorded on the emergency department note? Multiple select question. Patient assessment Clinical preferences of the patient Plan of care Diagnostic tests	back 126 Patient assessment Plan of care Diagnostic tests
front 127 Select all that apply Which health care provider works with radiological procedures? Multiple select question. Phlebotomist Radiologist Radiology technician Ultrasonagrapher Pharmacist	back 127 Radiologist Radiology technician Ultrasonagrapher
front 128 Select all that apply Which of the following parts of the SOAP method are heavily used to document an admission summary? Multiple select question. Subjective Referrals Objective Transfer of care	back 128 Subjective Objective

front 129 A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health is the ______. Multiple choice question. family history. chief complaint. review of systems. social history.	back 129 social history.
front 130 What factor in the discharge summary is different from the general SOAP documentation method? Multiple choice question. The note will have the plan of care. There is no difference. The note will lead with the diagnosis. The note will have the patient's medical history.	back 130 The note will lead with the diagnosis.
front 131 Select all that apply Which of the following are acceptable methods of documentation in the patient's chart? Multiple select question. Dictated Electronic Sticky note Handwritten	back 131 Dictated Electronic Handwritten
front 132 Select all that apply Which of the following are the elements documented in the operative report prepared by the surgeon? Multiple select question. Procedure performed Patient surgical outcome Events that transpired Patient's future appointments	back 132 Procedure performed Patient surgical outcome Events that transpired

front 133 Consultation notes are written by the consulting physician and sent to the ______. Multiple choice question. radiologist PCP MA pathologist	back 133 PCP
front 134 Select all that apply What is the name of the report documented by the health care provider who assesses the patient's care each day? Multiple select question. Daily Report Progress Note Clinic Notes Discharge Summary	back 134 Daily Report Progress Note
front 135 Most patients seen by the medical staff in an emergency department are what type of patients? Multiple choice question. Surgical Established New Inpatient	back 135 New
front 136 Select all that apply Which of the following are documented on the radiology report? Multiple select question. How image was performed Reason image was ordered Patient's past and social history Radiologist assessment	back 136 How image was performed Reason image was ordered Radiologist assessment

front 137 The assessment is also known as a(n) ______. Multiple choice question. differential diagnosis. chief complaint. history of present illness. review of systems.	back 137 differential diagnosis.
front 138 Select all that apply Which of the following is mentioned in a pathology report? Multiple select question. Pathologist's assessment Reason for the study Consultation note What was seen in detail	back 138 Pathologist's assessment Reason for the study What was seen in detail
front 139 Select all that apply Which of the following are documented in the discharge summary of a patient? Multiple select question. What happened during patient's stay at the hospital What types of follow-up are required How patient felt when admitted The patient's visitors during hospital stay	back 139 What happened during patient's stay at the hospital What types of follow-up are required How patient felt when admitted
front 140 The second line of the prescription, which provides the patient's instructions, is the Multiple choice question. dispense. rx. sig. refill.	back 140 sig.

front 141 Name the report documented after a surgery was performed by the surgeon. Multiple choice question. Consult note Operative report Discharge summary Clinic note	back 141 Operative report
front 142 Which of the following abbreviations means "after surgery"? Multiple choice question. ECU NICU Pre-op Post-op	back 142 Post-op
front 143 Which of the following documentation is a focus on the daily report/progress note? Multiple choice question. Assessment Subjective part Objective part Plan of care	back 143 Subjective part
front 144 Which of the following is the abbreviation for left? Multiple choice question. L R + #	back 144 L

front 145 Which of the following report explains the reason for ordering a radiologic image. Multiple choice question. surgical note clinic note radiology discharge summary	back 145 radiology
front 146 Which of the following is the abbreviation for blood pressure? Multiple choice question. RR Ht BP VS	back 146 BP
front 147 The pathology report is very similar to which type of report? Multiple choice question. Discharge summary Radiology report Clinic note Emergency department note	back 147 Radiology report
front 148 Match the abbreviation associated with a patient chart with the correct definition.	back 148

front 149 The third line of the prescription, which tells the pharmacist how much medication to give the patient, is called ______. Multiple choice question. refill sig rx dispense	back 149 dispense
front 150 Match terminology used for recording symptoms or exam findings with the correct definition.	back 150