Chapter 05 Book Solutions : Documentation - Guide To Physical Exam PDF

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Download Chapter 05 Book Solutions : Documentation - Guide To Physical Exam PDF

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Chapter 05: Documentation Ball: Seidel’s Guide to Physical Examination, 9th Edition MULTIPLE CHOICE 1. Which part of the information contained in the patient’s record may be used in court? a. Subjective information only b. Objective information only c. Diagnostic information only d. All information ANS: D

Anything that is entered into a patient’s record, in paper or electronic form, is a legal document and can DIF: Cognitive Level: Remembering (Knowledge) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 2. Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last

her house to go to college. Rather than infer the cause of Ms. S’s loss of appetite, it would be better to: a. defer or omit her comments. b. have her husband call you. c. quote her concerns verbatim. d. refer her for psychiatric treatment. ANS: C

It is best to document what you observe and what is said by the patient rather than documenting your int quoting exactly what the patient says is the better rule to follow. DIF: Cognitive Level: Applying (Application) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 3. Which is an effective adjunct to document the location of findings during the recording of the physical e a. Relationship to anatomic landmarks b. Computer graphics c. Comparison with other patients of same gender and size d. Comparison to previous examinations using light pen markings ANS: A

Abnormal or normal findings are best described in relationship to universal topographic and anatomic la DIF: Cognitive Level: Understanding (Comprehension) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 4. The position on a clock, topographic notations, and anatomic landmarks: a. are methods for recording locations of findings. b. are used for noting disease progression. c. are ways for recording laboratory study results. d. should not be used in the legal record. ANS: A

Descriptions of the locations of findings are universally referenced by using positions on a clock, topogr anatomic landmarks. DIF: Cognitive Level: Remembering (Knowledge) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 5. Regardless of the origin, discharge is described by noting: a. a grading scale of 0 to 4.

b. c. d.

color and consistency. demographic data and risk factors. associated symptoms in alphabetic order.

ANS: B

6. Drawing of stick figures is most useful to: a. compare findings in extremities. b. demonstrate radiation of pain. c. indicate consistency of lymph nodes. d. indicate mobility of masses. ANS: A

Simple drawings, such as stick figures, are more practical illustrations for findings in extremities. Radiat lymph nodes, and mobility of masses would not be adequately described by such simple drawings. DIF: Cognitive Level: Applying (Application) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 7. Which is an example of a problem that requires recording on the patient’s problem list? a. Common age variations b. Expected findings c. Problems needing further evaluation d. Minor variations ANS: C

Any problem is worth noting on the patient problem list, even if the cause or significance is unknown. C expected findings, and minor variations within normal limits should not be classified as a problem. DIF: Cognitive Level: Applying (Application) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 8. A problem may be defined as anything that will require: a. evaluation. b. medication. c. surgery. d. treatment. ANS: A

The need for further evaluation or attention indicates a problem. If a problem is found, it does not necess surgery, or treatment. DIF: Cognitive Level: Remembering (Knowledge) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 9. Differential diagnoses belong in the: a. history. b. physical examination. c. assessment. d. plan. ANS: C

Differential diagnoses for problems that have not been diagnosed are placed in the assessment category differentials are prioritized, and contributing factors are identified. DIF: Cognitive Level: Remembering (Knowledge) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 10. Which of the following is not a component of the plan portion of the problem-oriented medical record? a. Diagnostics ordered b. Therapeutics c. Patient education d. Differential diagnosis ANS: D

The differential diagnosis is part of the assessment phase.

DIF: Cognitive Level: Understanding (Comprehension) OBJ: Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort...