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30 terms

Clinical Skills 1

STUDY
PLAY
What should the medical assistant do if a patient refuses to answer a question regarding sexual history during patient interview?
Attempt to return to the question later once the patient is more at ease.
Subjective
sysmptoms and patient's complaint
plan
further tests and treatment
objective
vital signs
assessment
weigh subjective and objective finding
medical problems of siblings and parents
family history
smoke tobacco or drink alcohol
social history
all health problems, illnesses, and surgeries
medical history
Which is considered the physician's chief concern?
disease
Which of the following components of the review of systems includes joint stiffness, muscle pain, and limitation of movement?
musculoskeletal
Which of the following components of the review of systems would include shortness of breath?
respiratory
Which of the following best describes the patient's idea of treatment success?
being able to successfully manage the disease
You have picked up your equipment and supplies to obtain a medical history from a new patient. You introduce yourself to the patient after confirming her identity. Then you attempt to put her at ease. What is the next thing you should do?
Explain purpose and importance of information gathering.
Which of the following is the most appropriate action when the medical assistant is taking the medical history?
Ask the patient whether there are any questions; keeping them at ease.
Which is considered the patient's chief concern?
illness
Which of the following is not a purpose for the patient's medical history?
allows patient to help with diagnosis
Which of the following components of the review of systems would include heart palpitations?
cardiovascular
Which of the following components of the review of systems would include diarrhea?
gastrointestinal
greater than
>
less than
<
Which of the following components of the review of systems would include change in speech?
neurological
Which part of the medical history includes notes about location, quality, and timing?
present illness
Which of the following best describes the physician's overall assessment of major body functions?
review of systems
Which of the following is not a common medical records format?
patient-oriented
Information such as the patient's full name, address, and telephone number would be found on what form?
demographic data form
Which of the following is the most appropriate action to make a correction when an error has been made in the chart?
Draw a single line through error. Write correct entry and put initials and date.
Which of the following best describes the format of a source-oriented medical record?
chronological set of notes for each visit
In the SOAPER charting method, what does the letter "E" represent?
education
Which of the following is not included on the patient's medical history form?
insurance history
Which of the following is not a method used for charting?
SWISS