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Chapter 05: Documentation Ball: Seidel’s Guide to Physical Examination, 9th Edition/; DOWNLOAD TO SCORE A

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Chapter 05: Documentation Ball: Seidel’s Guide to Physical Examination, 9th Edition MULTIPLE CHOICE 1. During the course of the interview, you should: 2. Subjective and symptomatic data... are: 3. The quality of a symptom, such as pain, is subjective information that should be: 4. Drawing of stick figures is most useful to: 5. Which of the following is an example of a problem requiring recording on the patient’s problem list? 6. Differential diagnoses belong in the: 7. When recording assessments during the construction of the problem-oriented medical record, the examiner should: 8. Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical examination. This visit would be documented by creating a(n): 9. The effect of the chief concern on the patient’s lifestyle is recorded in which section of the medical record? 10. The patient’s perceived disabilities and functional limitations are recorded in the: 11. The review of systems is a component of the: 12. Allergies to drugs and foods are generally listed in which section of the medical record? 13. Objective data are usually recorded: 14. Information recorded about aNnUinRfaSnIt dNifGfeTrsBf.roCmOthMat of an adult, mainly because of the infant’s: 15. In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data? 16. Data relevant to the social history of older adults include information on: 17. A SOAP note is used in which type of recording system? 18. The examiner’s evaluation of a patient’s mental status belongs in the: 19. When recording physical findings, which data are recorded first for all systems? 20. Regarding another provider’s documented work, it: 21. Which of the following abbreviations is approved by The Joint Commission on Accreditation of Hospitals? [Show More]

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