1. When reading a medical record, you notice the following documentation: Patient states, "I have had low back pain and burning sensation every time that I urinate in the past days and is worsening, and now I am having fever and chills." This is an example of: a. Past history b. A Review of systems A functional assessment d. A reason for seeking care / chief complaint C. ANSWER: RATIONALE: 2. Which of the following actions is most appropriate to verify the reliability of the information provided by the patient during the interview? a. Provide the patient with a printed history to complete and then compare the data provided b. Rephrase the same questions later in the interview Review the patient's previous medical records. d. Call the nearest relative to verify the data provided. С. ANSWER: RATIONALE: 3. During an interview for health history, the student nurse asks, "Mrs Cassandra O'Connor, what do you do when you experience chest pain?" the student nurse is seeking which of the following information? The client's perception of the problem. b. Aggravating or relieving factors The frequency of the problem d. The severity of the problem а. С. ANSWER: RATIONALE: 4. Which of the following statements is an appropriate documentation of the client's reason for seeking health care or the chief complaint? a. Acute episode of Meniere's disease, duration 2 hours b. Dizziness with nausea and vomiting, 2-hour duration C. "Spinning" sensation of the body for 2 hours d. Abnormal hearing test results. ANSWER: RATIONALE:. 5. A review of systems (ROS) provides which of the following information? a. An evaluation of the past and present health state of each body system b. A documentation of the objective findings of the nurse. C. A documentation of the current health problems of the patient.
1. When reading a medical record, you notice the following documentation: Patient states, "I have had low back pain and burning sensation every time that I urinate in the past days and is worsening, and now I am having fever and chills." This is an example of: a. Past history b. A Review of systems A functional assessment d. A reason for seeking care / chief complaint C. ANSWER: RATIONALE: 2. Which of the following actions is most appropriate to verify the reliability of the information provided by the patient during the interview? a. Provide the patient with a printed history to complete and then compare the data provided b. Rephrase the same questions later in the interview Review the patient's previous medical records. d. Call the nearest relative to verify the data provided. С. ANSWER: RATIONALE: 3. During an interview for health history, the student nurse asks, "Mrs Cassandra O'Connor, what do you do when you experience chest pain?" the student nurse is seeking which of the following information? The client's perception of the problem. b. Aggravating or relieving factors The frequency of the problem d. The severity of the problem а. С. ANSWER: RATIONALE: 4. Which of the following statements is an appropriate documentation of the client's reason for seeking health care or the chief complaint? a. Acute episode of Meniere's disease, duration 2 hours b. Dizziness with nausea and vomiting, 2-hour duration C. "Spinning" sensation of the body for 2 hours d. Abnormal hearing test results. ANSWER: RATIONALE:. 5. A review of systems (ROS) provides which of the following information? a. An evaluation of the past and present health state of each body system b. A documentation of the objective findings of the nurse. C. A documentation of the current health problems of the patient.
Understanding Health Insurance: A Guide to Billing and Reimbursement
14th Edition
ISBN:9781337679480
Author:GREEN
Publisher:GREEN
Chapter10: Coding Compliance, Clinical Documentation Improvement, And Coding For Medical Necessity
Section: Chapter Questions
Problem 4R
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Transcribed Image Text:1. When reading a medical record, you notice the following documentation: Patient states, "f have had Tow
back pain and burning sensation every time that I urinate in the past days and is worsening, and now I am
having fever and chills." This is an example of:
a. Past history
b. A Review of systems
c. A functional assessment
d. A reason for seeking care / chief complaint
ANSWER:
RATIONALE:
2. Which of the following actions is most appropriate to verify the reliability of the information provided by
the patient during the interview?
a. Provide the patient with a printed history to complete and then compare the data provided
b. Rephrase the same questions later in the interview
Review the patient's previous medical records.
d. Call the nearest relative to verify the data provided.
с.
ANSWER:
RATIONALE:
3. During an interview for health history, the student nurse asks, "Mrs Cassandra O'Connor, what do you do
when you experience chest pain?" the student nurse is seeking which of the following information?
The client's perception of the problem.
b. Aggravating or relieving factors
The frequency of the problem
d. The severity of the problem
а.
С.
ANSWER:
RATIONALE:_
4. Which of the following statements is an appropriate documentation of the client's reason for seeking
health care or the chief complaint?
Acute episode of Meniere's disease, duration 2 hours
Dizziness with nausea and vomiting, 2-hour duration
c. "Spinning" sensation of the body for 2 hours
d. Abnormal hearing test results.
а.
b.
ANSWER:
RATIONALE:
5. A review of systems (ROS) provides which of the following information?
An evaluation of the past and present health state of each body system
b. A documentation of the objective findings of the nurse.
A documentation of the current health problems of the patient.
а.
С.
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