EHR – Ch #4
c) menu item
a) patient’s name
b) provider’s name
c) form name
d) patient’s chart number
The name of the form should be related to its purpose, such as “Patient History” or “Physical Exam.”
b) current medications
c) marital status
d) dates of previous surgery
Marital status is a piece of social data.
a) name of operation
b) name of surgeon
c) approximate date of the operation
d) name of the anesthesiologist
a) chief complaint
b) history of present illness
d) past medical history
a) physical exam
b) patient medical history
c) review of systems
d) social history
Physicians “inventory” the various body systems to determine if there are any signs or symptoms which might point to particular medical conditions.
The patient’s chief complaint is confusion, and that is the reason she had an appointment on July 5, 2011.
Looking at the social history, it is noted that the patient is married.
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.
The original must be corrected in the electronic record. The original will remain retrievable, but the correct information will be visible as well.
a) heart rate
b) blood pressure
c) body mass index
d) complete blood count
A complete blood count is a laboratory test, not a vital sign.