Patient Assessment & Documentation Flashcards
7 cards from real MS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
When documenting a patient's pain level in the HPI, which standardized scale is most commonly used in US emergency departments?
Answer: Numeric Rating Scale (0-10)
The Numeric Rating Scale from 0 (no pain) to 10 (worst imaginable) is the standard pain assessment tool used in US emergency departments.
A scribe documents 'PMH: HTN, DM2, CAD.' What does 'PMH' stand for?
Answer: Past Medical History
PMH stands for Past Medical History, which lists previously diagnosed conditions.
Which component of the SOAP note contains the physician's diagnosis and treatment plan?
Answer: Assessment
The Assessment section contains the physician's clinical impression, differential diagnoses, and working diagnosis.
A patient reports dizziness that worsens when standing. The correct medical term for this is:
Answer: Orthostatic hypotension
Orthostatic hypotension describes a drop in blood pressure upon standing, which typically causes dizziness.
In the ROS, the scribe documents that the patient denies shortness of breath, cough, or wheezing. This is documented under which system?
Answer: Respiratory
Shortness of breath, cough, and wheezing are symptoms belonging to the respiratory (pulmonary) system.
Which abbreviation correctly documents that a patient has no known drug allergies?
Answer: NKDA
NKDA stands for No Known Drug Allergies and is the standard abbreviation used in medical documentation.
A physician documents 'A&Ox3.' What does this notation indicate?
Answer: The patient is alert and oriented to person, place, and time
A&Ox3 means alert and oriented to three spheres: person, place, and time.
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