Chapter 2 Introduction to Health Records

Chapter 2.1 The SOAP Method

Chapter 2.1 The SOAP Method

Learning Outcome 2.1 Exercises: Exercise 1.

1. c

2. a

3. d

4. a

5. c

6. c

7. a

Learning Outcome 2.1 Exercises: Exercise 2.

1. c

2. d

3. a

4. b

Learning Outcome 2.1 Exercises: Exercise 3, 4.

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Subjective

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Subjective: General Subjective Terms Table

Learning Outcome 2.2 Exercises: Exercise 1, 2.

Learning Outcome 2.2 Exercises: Exercise 3, 4.

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Objective

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Objective: General Objective Terms Table

Learning Outcome 2.2 Exercises: Exercise 6, 7, 8.

Learning Outcome 2.2 Exercises: Exercise 9, 10.

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Assessment

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Assessment: General Assessment Terms Table

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Assessment: Public Health Table

Learning Outcome 2.2 Exercises: Exercise 11, 12.

Learning Outcome 2.2 Exercises: Exercise 13.

Learning Outcome 2.2 Exercises: Exercise 14.

Learning Outcome 2.2 Exercises: Exercise 15.

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Plan

Chapter 2.2 Common Terms in Medicine

Your Future Second-Nature Words -

1. Plan: General Plan Terms Table & Public Health Table

Learning Outcome 2.2 Exercises: Exercise 16, 17.

Learning Outcome 2.2 Exercises: Exercise 18, 19.

Chapter 2.2 Common Terms in Medicine

Body Planes and Orientation

Chapter 2.2 Common Terms in Medicine

Body Planes and Orientation

1. Opposites Table: Part 1.

Chapter 2.2 Common Terms in Medicine

Body Planes and Orientation

1. Opposites Table: Part 2.

Chapter 2.2 Common Terms in Medicine

Body Planes and Orientation

1. Opposites Table: Part 3.

Chapter 2.2 Common Terms in Medicine

Body Planes and Orientation

1. Opposites Table: Part 4.

Chapter 2.2 Common Terms in Medicine

Body Planes and Orientation

1. Body Planes Table

Learning Outcome 2.2 Exercises: Exercise 20, 21.

Learning Outcome 2.2 Exercises: Exercise 22, 23.

Learning Outcome 2.2 Exercises: Exercise 24.

Chapter 2.2 Common Terms in Medicine

Health Professionals

Chapter 2.2 Common Terms in Medicine

Health Professionals

1. Health Professions Table: Part 1.

Chapter 2.2 Common Terms in Medicine

Health Professionals

1. Health Professions Table: Part 2.

Learning Outcome 2.2 Exercises: Exercise 25.

Learning Outcome 2.2 Exercises: Exercise 26, 27.

Chapter 2.3 Common Terms in Medicine

Types of Health Records

Chapter 2.3 Common Terms in Medicine

Types of Health Records

1. Sections of a Health Record Table

Chapter 2.3 Common Terms in Medicine

Example Note #1: Clinic Note

Chapter 2.3 Common Terms in Medicine

Example Note #1: Clinic Note Example

Chapter 2.3 Common Terms in Medicine

Example Note #2: Consult Note

Chapter 2.3 Common Terms in Medicine

Example Note #2: Consult Note Example

Chapter 2.3 Common Terms in Medicine

Example Note #3: Emergency Department Note

Chapter 2.3 Common Terms in Medicine

Example Note #3: Emergency Department Note Example

Chapter 2.3 Common Terms in Medicine

Example Note #4: Admission Summary

Chapter 2.3 Common Terms in Medicine

Example Note #4: Admission Summary Example

Chapter 2.3 Common Terms in Medicine

Example Note #5: Discharge Summary

Chapter 2.3 Common Terms in Medicine

Example Note #5: Discharge Summary Example

Chapter 2.3 Common Terms in Medicine

Example Note #6: Operative Report

Chapter 2.3 Common Terms in Medicine

Example Note #6: Operative Report Example

Chapter 2.3 Common Terms in Medicine

Example Note #7: Daily Hospital Note/Progress Note

Chapter 2.3 Common Terms in Medicine

Example Note #7: Daily Hospital Note/Progress Note Example

Chapter 2.3 Common Terms in Medicine

Example Note #8: Radiology Report

Chapter 2.3 Common Terms in Medicine

Example Note #8: Radiology Report Example

Chapter 2.3 Common Terms in Medicine

Example Note #9: Pathology Report

Chapter 2.3 Common Terms in Medicine

Example Note #9: Pathology Report Example

Chapter 2.3 Common Terms in Medicine

Example Note #10: Prescription

Chapter 2.3 Common Terms in Medicine

Example Note #10: Prescription Example

Chapter 2.3 Common Terms in Medicine

1. Summary of Health Records Table: Part 1.

Chapter 2.3 Common Terms in Medicine

1. Summary of Health Records Table: Part 2.

Learning Outcome 2.3 Exercises: Exercise 1, 2.

Learning Outcome 2.3 Exercises: Exercise 3.

Learning Outcome 2.3 Exercises: Exercise 4.

Learning Outcome 2.3 Exercises: Exercise 5.

Learning Outcome 2.3 Exercises: Exercise 6.

Learning Outcome 2.3 Exercises: Exercise 7.

Learning Outcome 2.3 Exercises: Exercise 7 Part 2.

Learning Outcome 2.3 Exercises: Exercise 8.

Chapter 2.4 Abbreviations

Abbreviations Associated with Health Care Facilities

Chapter 2.4 Abbreviations

Abbreviations Associated with Health Care Facilities

1. Health Care Facility Abbreviations Table

Learning Outcome 2.4 Exercises: Exercise 1.

Learning Outcome 2.4 Exercises: Exercise 2, 3.

Chapter 2.4 Abbreviations

Abbreviations Associated with Patient Care

1. Symbols Table

Chapter 2.4 Abbreviations

Abbreviations Associated with Patient Care

1. Abbreviations Common on Health Records Table

Chapter 2.4 Abbreviations

Abbreviations Associated with Patient Care

1. Abbreviations used for Symptoms or Exam Findings Table

Chapter 2.4 Abbreviations

Abbreviations Associated with Patient Care

1. Abbreviations Associated with Orders and Administering Medicine Table

Learning Outcome 2.4 Exercises: Exercise 4.

Learning Outcome 2.4 Exercises: Exercise 5.

Learning Outcome 2.4 Exercises: Exercise 6.

Learning Outcome 2.4 Exercises: Exercise 7.

Chapter 2.4 Abbreviations

Timing- and Frequency-Based Abbreviations

Chapter 2.4 Abbreviations

Timing- and Frequency-Based Abbreviations

1. Timing Abbreviations Table

Learning Outcome 2.4 Exercises: Exercise 8, 9.

Learning Outcome 2.4 Exercises: Exercise 10.

Chapter 2.5 Electronic Health Records

Clinic Note

Chapter 2.5 Electronic Health Records

Clinic Note

1. Clinic Note Example

Learning Outcome 2.5 Exercises: Exercise 1, 2, 3.

Learning Outcome 2.5 Exercises: Exercise 4.

Chapter 2.5 Electronic Health Records

Consult Note

1. Consult Note Sample Health Record (goes with Exercise 5)

Learning Outcome 2.5 Exercises: Exercise 5.

Chapter 2.5 Electronic Health Records

Emergency Department Note

1. Emergency Department Note Sample Health Record (goes with Exercise 7)

Learning Outcome 2.5 Exercises: Exercise 6.

Learning Outcome 2.5 Exercises: Exercise 7, 8.

Chapter 2.5 Electronic Health Records

Admission Note

1. Admission Note Sample Health Record (goes with Exercise 10)

Learning Outcome 2.5 Exercises: Exercise 9, 10.

Learning Outcome 2.5 Exercises: Exercise 11.

Learning Outcome 2.5 Exercises: Exercise 12.

Learning Outcome 2.5 Exercises: Exercise 13.

Chapter 2.5 Electronic Health Records

Discharge Summary

1. Discharge Summary Sample Health Record (goes with Exercise 14)

Learning Outcome 2.5 Exercises: Exercise 14.

Learning Outcome 2.5 Exercises: Exercise 15, 16.

Learning Outcome 2.5 Exercises: Exercise 17.

Chapter 2.5 Electronic Health Records

Operative Report

1. Operative Report Sample Health Record (goes with Exercise 18)

Learning Outcome 2.5 Exercises: Exercise 18.

Chapter 2.5 Electronic Health Records

Daily Hospital Note/Progress Note

1. Operative Report Sample Health Record (goes with Exercise 19)

Learning Outcome 2.5 Exercises: Exercise 19, 20.

Learning Outcome 2.5 Exercises: Exercise 21.

Chapter 2.5 Electronic Health Records

Radiology Report

1. Radiology Report Sample Health Record (goes with Exercise 22)

Learning Outcome 2.5 Exercises: Exercise 22.

Chapter 2.5 Electronic Health Records

Pathology Report

1. Pathology Report Sample Health Record (goes with Exercise 23)

Learning Outcome 2.5 Exercises: Exercise 23.

Chapter 2.5 Electronic Health Records

Prescription

1. Prescription Example

Learning Outcome 2.5 Exercises: Exercise 24.

Learning Outcome 2.5 Exercises: Exercise 25.

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

• Previous illnesses
• Medications
• Treatments to the patient

Data compiled through laboratory findings is considered ______.

Multiple choice question.

• Plan
• Subjective
• Assessment
• Objective

Objective

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

• Timing of the problem
• Current medications
• Reason for the visit

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

Tests

Which of the following terms would be used to describe "assessment"?

Multiple choice question.

• Degeneration
• Diagnosis
• Impression
• Benign
• Malignant

Impression

What is the abbreviation for "Electronic Health Record"?

Multiple choice question.

• EMR
• EHR
• CMS
• SOAP

EHR

What happened to the patient at the end of the visit is

Multiple choice question.

• disposition.
• palliative.
• prophylaxis.
• observation.

disposition.

Forming a logical analysis is in the ______ part of the SOAP method.

assessment

Match the different types of planes term to the definition.

The ______ section of a health record tells the patient's story of their health issues.

Multiple choice question.

• assessment
• objective
• subjective
• plan

subjective

Select all that apply

Which of the following terms are used to identify the back?

Multiple select question.

• Posterior
• Dorsal
• Ventral
• Anterior

• Posterior
• Dorsal

In the SOAP method, the ______ part of a health record tells about the data collected during the visit to the doctor.

objective

Drag and drop the definitions against the corresponding terms.

Match each general assessment term with the correct definition.

Match each general plan term with the correct definition.

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

Lying down on back

Which position is standing facing forward, arms at the side with the palms forward?

Multiple choice question.

• Supine
• Prone
• Anatomic
• Distal

Anatomic

Which of the following terms describes the palm of the hand?

Multiple choice question.

• Unilateral
• Palmar
• Plantar
• Dorsal

Palmar

Select all that apply

Which of the following terms are used to identify the front?

Multiple select question.

• Antral
• Anterior
• Ventral
• Superior
• Dorsal

• Antral
• Anterior
• Ventral

The body plane that divides the body in slices right to left is

Multiple choice question.

• transverse.
• frontal.
• sagittal.
• coronal.

sagittal.

The term ______ describes the term "the front" in body positioning.

Blank 1: anterior, ventral, or antral

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

Respiratory Therapist

Match the terminology for assessment terms with the correct definition.

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

Phlebotomist

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

Lying down on belly

Select the color coding to the section of the SOAP method.

The sole of the foot is called ______.

plantar

Which of the following is the documentation method used for charting in the medical record?

Multiple choice question.

• ABN
• EOB
• SOAP
• HHS

SOAP

Match the different types of body planes to their definition.

What type of documentation format is used for consultation notes?

Multiple choice question.

• RA
• MSP
• EOB
• SOAP

SOAP

Match the health care professional with the job description.

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

• Patient assessment
• Plan of care
• Diagnostic tests

Select all that apply

Which health care provider works with radiological procedures?

Multiple select question.

• Phlebotomist
• Radiologist
• Radiology technician
• Ultrasonagrapher
• Pharmacist

• Radiologist
• Radiology technician
• Ultrasonagrapher

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

• Subjective
• Objective

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.

social history.

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.

The note will lead with the diagnosis.

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

• Dictated
• Electronic
• Handwritten

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

• Procedure performed
• Patient surgical outcome
• Events that transpired

Consultation notes are written by the consulting physician and sent to the ______.

Multiple choice question.

• radiologist
• PCP
• MA
• pathologist

PCP

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

• Daily Report
• Progress Note

Most patients seen by the medical staff in an emergency department are what type of patients?

Multiple choice question.

• Surgical
• Established
• New
• Inpatient

New

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

• How image was performed
• Reason image was ordered
• Radiologist assessment

The assessment is also known as a(n) ______.

Multiple choice question.

• differential diagnosis.
• chief complaint.
• history of present illness.
• review of systems.

differential diagnosis.

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

• Pathologist's assessment
• Reason for the study
• What was seen in detail

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

• What happened during patient's stay at the hospital
• What types of follow-up are required
• How patient felt when admitted

The second line of the prescription, which provides the patient's instructions, is the

Multiple choice question.

• dispense.
• rx.
• sig.
• refill.

sig.

Name the report documented after a surgery was performed by the surgeon.

Multiple choice question.

• Consult note
• Operative report
• Discharge summary
• Clinic note

Operative report

Which of the following abbreviations means "after surgery"?

Multiple choice question.

• ECU
• NICU
• Pre-op
• Post-op

Post-op

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

Subjective part

Which of the following is the abbreviation for left?

Multiple choice question.

• L
• R
• +
• #

L

Which of the following report explains the reason for ordering a radiologic image.

Multiple choice question.

• surgical note
• clinic note
• radiology
• discharge summary

radiology

Which of the following is the abbreviation for blood pressure?

Multiple choice question.

• RR
• Ht
• BP
• VS

BP

The pathology report is very similar to which type of report?

Multiple choice question.

• Discharge summary
• Radiology report
• Clinic note
• Emergency department note

Radiology report

Match the abbreviation associated with a patient chart with the correct definition.

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

dispense

Match terminology used for recording symptoms or exam findings with the correct definition.