MS Patient Assessment & Documentation 2 — Questions and Answers
Question 1: When documenting a patient's pain level in the HPI, which standardized scale is most commonly used in US emergency departments?
- Glasgow Coma Scale
- Numeric Rating Scale (0-10) (Correct answer)
- Apgar Score
- Modified Early Warning Score
Correct 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.
Question 2: A scribe documents 'PMH: HTN, DM2, CAD.' What does 'PMH' stand for?
- Primary Medical History
- Past Medical History (Correct answer)
- Pertinent Medical History
- Patient Medical Highlights
Correct answer: Past Medical History
PMH stands for Past Medical History, which lists previously diagnosed conditions.
Question 3: Which component of the SOAP note contains the physician's diagnosis and treatment plan?
- Subjective
- Objective
- Assessment (Correct answer)
- Plan
Correct answer: Assessment
The Assessment section contains the physician's clinical impression, differential diagnoses, and working diagnosis.
Question 4: A patient reports dizziness that worsens when standing. The correct medical term for this is:
- Vertigo
- Syncope
- Orthostatic hypotension (Correct answer)
- Presyncope
Correct answer: Orthostatic hypotension
Orthostatic hypotension describes a drop in blood pressure upon standing, which typically causes dizziness.
Question 5: In the ROS, the scribe documents that the patient denies shortness of breath, cough, or wheezing. This is documented under which system?
- Cardiovascular
- Respiratory (Correct answer)
- Gastrointestinal
- Neurological
Correct answer: Respiratory
Shortness of breath, cough, and wheezing are symptoms belonging to the respiratory (pulmonary) system.
Question 6: Which abbreviation correctly documents that a patient has no known drug allergies?
- NKFA
- NDA
- NKDA (Correct answer)
- NAD
Correct answer: NKDA
NKDA stands for No Known Drug Allergies and is the standard abbreviation used in medical documentation.
Question 7: A physician documents 'A&Ox3.' What does this notation indicate?
- The patient is ambulatory and mobile
- The patient is alert and oriented to person, place, and time (Correct answer)
- The patient has three comorbidities
- The patient's anxiety level is at scale 3
Correct 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.
MS Patient Assessment & Documentation 2
When documenting a patient's pain level in the HPI, which standardized scale is most commonly used in US emergency departments?