Recording your exam

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Recording the exam

note tenderness (a sign) in the record; or report the patient's reaction

when a patient complains of pain (a symptom) during palpation, you should note tenderness (a sign) in the record; or report the patient's reaction to pain, such as crying, withdrawal, rigid posturing, or facial expression. Record expected and unexpected findings; both what the patient tells you and what you observe

placed in the history section

Subjective and symptomatic data are:

quote her concerns verbatim

Ms. S. reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S.'s loss of appetite, it would be better to

described in the history

It is best to document what you observe and what is said by the patient rather than document your interpretations. Listening and quoting exactly what the patient says is the better rule to follow.
The quality of a symptom, such as pain, is subjective information that should be:

Relationship to anatomic landmarks

Which of the following is an effective adjunct to document location of findings during the recording of physical examinations?

are methods for recording locations of findings

The position on a clock, topographic notations, and anatomic landmarks

color and consistency

Regardless of the origin, discharge is described by noting

compare findings in extremities

Drawing of stick figures is most useful to:

plan

Differential diagnoses belong in the

create an assessment for each problem on the problem list

When recording assessments during the construction of the problem-oriented medical record, the examiner should:

differential diagnosis is part of the assessment phase.

Which of the following is not a component of the plan portion of the problem-oriented medical record?

progress note

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n):

history of present illness.

A detailed description of the symptoms related to the chief complaint is presented in the

effect of the patient's complaint on current everyday lifestyle or work performance is recorded in the history of present illness

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record

past medical history disabilities or functional limitations that alter activities of daily living.

The patient's perceived disabilities and functional limitations are recorded in the:

health history

The review of systems is a component of the:

past medical history

Allergies to drugs and foods are generally listed in which section of the medical record?

present problem

In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?

History of present illness

The effect of the chief complaint on the patient's lifestyle is recorded in which section of the medical record?

past medical histroy

The patient's perceived disabilities and functional limitations are recorded in the

health history

The review of systems is a component of the:

physical examination

The examiner's evaluation of a patient's mental status belongs in the:

Brief SOAP note

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

GM. is a 22-year-old male here for having "green nasal discharge" for the past 72 hours.

a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care?

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