Physical Examination and B. Discharge Summary

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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
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Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI).
A. location
B. timing
C. severity
D. modifying factors

9. The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient 's visit.
A. care plan
B. charges
C. diagnosis
D. assessment 10. Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the __________________ system.
A. gastrointestinal
B. head/eyes/ears/nose/mouth
C. respiratory
D. cardiovascular 11. The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?
A. general
B. gastrointestinal
C. neurologic
D. constitutional 12. Which of the following professionals would not perform a physical examination (PE)?
A. medical assistant
B. physician 's assistant
C. nurse midwife
D. nurse practitioner 13. The healthcare professional who types reports for care providers is known as a/an ______________.
A. dictator
B. transcriptionist
C. transcriber
D. scribe

14. Which of the following is an advantage of dictation and transcription?
A. most physicians prefer it to

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