EMR Chapter 5 Assessment

In a hospital setting, the care provider takes the patient's history, details the reason the patient is being admitted, and performs a physical exam. The report of this information is known as the:

history and physical

In a hospital setting, what document is the equivalent of the assessment and plan that is collected as part of a SOAP note in an outpatient record?

discharge summary

Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________blank data.

unstructured

Dr. Schultz has just examined Natalia Shrier who had come to see him because she has been having increasing problems with gastroesophageal reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to avoid eating within three hours of going to bed, to raise the head of her bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's instructions are part of which element in a SOAP note?

Plan

Alison Holt just received a copy of her Clinical Visit Summary from the visit to her primary care provider earlier in the day. She is reading that her symptoms were present for the past four days and that she did not get any relief from Motrin. To which section of the SOAP note does this information pertain?

Subjective

Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low-grade fever for the past four days. This is known as _________blank.

subjective information

A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the _________blank in a history of present illness (HPI).

severity

During the history, Kevin Goodell notes that the pain in his right hip is more of a dull pain than an ache. This is considered what part of the history of present illness (HPI)?

quality

Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the _________blank system.

respiratory

The review of systems (ROS) is documented for patient care purposes and also factors into the _________blank for the patient's visit.

care plan, charges, diagnosis, and assessment

The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?

constitutional

Which of the following professionals would not perform a physical examination (PE)?

medical assistant

Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _________blank are assistants who may enter the information.

Scribes

Which of the following is an advantage of dictation and transcription?

allows for greater accuracy of documentation than written notes

The healthcare professional who types reports for care providers is known as a/an _________blank.

transcriptionist

Which of the following is a benefit of voice recognition technology?

Documents are made part of the patient's record in a timelier manner.

Of the following, which is not a benefit of ePrescribing?

It is less expensive for the patient.

One of the reasons ePrescribing is being used by a greater number of physicians' practices is that it

is a requirement of the HITECH Meaningful Use, now Promoting Interoperability, regulations.

Which of the following is a benefit of CPOE?

Clinical decision support is possible through CPOE.

In order for any test, procedure, or medication to be administered to a patient, there must be a

care provider's order.

A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as

computerized physician order entry.

In EHRclinic, as with many other electronic health record systems, healthcare professionals and healthcare providers can access a patient's health record to determine the status of orders for testing or prescriptions. This is known as

order tracking.

If a computerized physician's order is sent to the local hospital for a blood test, and the physician's office has already been notified of the test findings, this order is

returned.

Emily Haver is being seen by Dr. Clark today for her annual physical exam. She has been a patient of his for many years. She is currently being treated for hypertension and type 2 diabetes mellitus. Between 2010 and 2015 she was treated on several occasions for poison ivy. She has been treated since 2017 with Zoloft for mild depression. Of the following, which will not appear on Emily Haver's problem list?

poison ivy

Promoting Interoperability (Meaningful Use) guidelines require the keeping of an up-to-date

problem list.