Physical Examination and B. Discharge Summary
Multiple Choice Questions 1. 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 _______________.
A. subjective information
B. objective information
C. an assessment
D. a diagnosis 2. 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:
A. initial progress note
B. discharge summary
C. history and physical
D. SOAP note 3. The SOAP documentation format is most commonly used in which healthcare setting?
A. hospital inpatient
B. physician 's office
C. hospital emergency department
D. outpatient diagnostic department 4. 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?
A. Subjective
B. Objective
C. Assessment
D. Plan
5. 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?
A. History and Physical
B. Discharge Summary
C. Progress note
D. Procedure note 6. 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)?
A. location
B. quality
C. severity
D. modifying factor 7. A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).
A. associated signs and symptoms
B. modifying factors
C.
A. subjective information
B. objective information
C. an assessment
D. a diagnosis 2. 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:
A. initial progress note
B. discharge summary
C. history and physical
D. SOAP note 3. The SOAP documentation format is most commonly used in which healthcare setting?
A. hospital inpatient
B. physician 's office
C. hospital emergency department
D. outpatient diagnostic department 4. 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?
A. Subjective
B. Objective
C. Assessment
D. Plan
5. 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?
A. History and Physical
B. Discharge Summary
C. Progress note
D. Procedure note 6. 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)?
A. location
B. quality
C. severity
D. modifying factor 7. A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).
A. associated signs and symptoms
B. modifying factors
C.