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Which of the following information would you place in the "S" section when using SOAP charting?


A) Physician's examination
B) Physician's diagnosis
C) Patient's perceptions
D) Test results
E) Patient education

F) A) and E)
G) A) and D)

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Which of the following would you place in the "A" section when using SOAP charting?


A) Physician's examination
B) Physician's diagnosis
C) Patient's perceptions
D) Test results
E) Patient education

F) All of the above
G) A) and B)

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Which of the following approaches allows you to determine the patient's knowledge of the situation and whether it is accurate?


A) Agreeing with the patient
B) Asking questions that require yes-or-no answers
C) Asking hypothetical questions
D) Probing for more information
E) Challenging the patient

F) A) and B)
G) B) and D)

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Asking the patient "What do you think about this?" allows the patient to evaluate the situation and form an opinion. This is an example of ____.


A) clarification
B) verbalization
C) reflection
D) hypothesizing
E) probing

F) B) and D)
G) None of the above

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Most patient charts are arranged with the entries in reverse _______ order.

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The use of alcohol, tobacco, recreational drugs, or other chemical substances is documented in the _______ history.

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social and...

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The method of collecting patient data that requires more than a yes-or-no answer is asking _________ questions.

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open-ended...

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Angel dust is also known as ____.


A) LSD
B) cocaine
C) PCP
D) opium
E) heroin

F) A) and D)
G) A) and B)

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The ________ is the reason the patient came to visit the practitioner. It should be short and specific and should cover subjective and/or objective data.

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The question "Where would you like to begin?" represents which method of data collection?


A) Asking open-ended questions
B) Asking hypothetical questions
C) Mirroring the patient's responses
D) Encouraging the patient to evaluate his situation
E) Encouraging the patient to take the lead

F) A) and B)
G) A) and C)

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The practitioner decides that the patient needs blood and urine tests. The practitioner will document this in the medical record under the _______ of action section in the SOAP format.

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Patient interviews should be conducted in ________ and without interruptions.

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The Joint Commission (TJC) issued a "Do Not Use" list of ________, acronyms, and symbols that should not be used in an effort to reduce medical errors.

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When you assume an open and relaxed body posture, you are demonstrating which data collection method?


A) Asking open-ended questions
B) Focusing on the patient
C) Asking hypothetical questions
D) Encouraging the patient to evaluate his situation
E) Agreeing with the patient

F) A) and B)
G) A) and D)

Correct Answer

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Which of the following is charted as subjective data?


A) Test results
B) Practitioner's examination
C) Patient's chief complaint
D) Vital signs
E) Plan of action

F) A) and B)
G) All of the above

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The history of ________ illness includes detailed information about the chief complaint, including when the problem started and what the patient has done to treat the problem.

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Many offices use a variation of the _______ note to document routine follow-ups of established patients with ongoing conditions such as hypertension or arthritis.

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Where on the health history form do you document information taken from the administrative sheet?


A) Personal data
B) Chief complaint
C) History of present illness
D) Social and occupational history
E) Family history

F) A) and D)
G) B) and C)

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When an office uses _______ medical records, the records are accessible at any time and combine SOMR and POMR methods.

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Effective ________ means hearing what the patient says, thinking about it, and responding appropriately.

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