EMR Chapter 4 Assessment

Every form should include the _________blank so that the form's use is obvious.

form name

Which of the following is not a vital sign?

complete blood count

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

review of systems.

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

chief complaint.

Emily Haver documented on her past history form that she had an arthroscopy of the right knee in 2018. On her next visit, the care provider was reviewing her past surgical history and mentioned that she 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?

Amend the record to show the corrected information, according to office policy.

What is the patient’s diagnosis on 5/9/2007?

shingles

You have just entered data into an online form. The box in which you entered the information is known as a

field.

What is the patient's marital status?

married

Of the following, which is part of the patient's social history?

marital status

Dr. Brown is questioning a patient about her past surgical history. Which piece of data would Dr. Brown not be interested in knowing?

name of the anesthesiologist(s) assigned to the patient at each operation