EHR – Ch #4

You have just entered data into an online form. The box in which you entered the information is known as a/an:
a) locator
b) field
c) menu item
d) space
b) field
Every form should include the _______________ so that the form’s use is obvious.
a) patient’s name
b) provider’s name
c) form name
d) patient’s chart number
c) form name

The name of the form should be related to its purpose, such as “Patient History” or “Physical Exam.”

Of the following, which is not part of the patient’s past medical or surgical history?
a) allergies
b) current medications
c) marital status
d) dates of previous surgery
c) marital status

Marital status is a piece of social data.

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Which of the following typically would not be collected as part of the past surgical history?
a) name of operation
b) name of surgeon
c) approximate date of the operation
d) name of the anesthesiologist
d) name of the anesthesiologist
Natalie Burns has just arrived for her 1:00 p.m. appointment with Dr. Earl. She informs the healthcare professional that she is there for a follow-up of her hypertension. This is known as Natalie’s:
a) chief complaint
b) history of present illness
c) diagnosis
d) past medical history
a) chief complaint
Craig James is in the office of Dr. Hammer for his annual physical. Dr. Hammer asks Craig a series of questions such as “do you have frequent headaches,” “do you have frequency of urination,” and “do you have difficulty sleeping.” These questions are part of the:
a) physical exam
b) patient medical history
c) review of systems
d) social history
c) review of systems

Physicians “inventory” the various body systems to determine if there are any signs or symptoms which might point to particular medical conditions.

What is the reason the patient made an appointment for July 5, 2011?
a) COPD
b) hypertension
c) lumbago
d) confusion
(Insert photo)
d) confusion

The patient’s chief complaint is confusion, and that is the reason she had an appointment on July 5, 2011.

What is the patient’s marital status?
Insert picture
married.

Looking at the social history, it is noted that the patient is married.

Emily Haver documented on her past history form that she had an arthroscopy of the right knee in 2005. On her next visit, the care provider was reviewing her past surgical history and mentioned that she had had right knee arthroscopy. The patient realized she had written the wrong side, and confirmed that it was her left knee which underwent arthroscopy. What action will the care provider take in this case?
a) Nothing, leave the documentation as is, since that is what the patient initially stated.
b) Place a paper note in the patient’s folder noting there is an error in the patient’s electronic record.
c) Amend the record to show the corrected information, according to office policy.
d) Have the office manager take care of it.
c) Amend the record to show the corrected information, according to office policy.

The original must be corrected in the electronic record. The original will remain retrievable, but the correct information will be visible as well.

Which of the following is not a vital sign?
a) heart rate
b) blood pressure
c) body mass index
d) complete blood count
d) complete blood count

A complete blood count is a laboratory test, not a vital sign.

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