MS Patient Assessment & Documentation 2

Question 1

When documenting a patient's pain level in the HPI, which standardized scale is most commonly used in US emergency departments?

Accepted Answer

Numeric Rating Scale (0-10)

Answer

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?

Accepted Answer

Past Medical History

Answer

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?

Accepted Answer

Assessment

Answer

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:

Accepted Answer

Orthostatic hypotension

Answer

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?

Accepted Answer

Respiratory

Answer

Shortness of breath, cough, and wheezing are symptoms belonging to the respiratory (pulmonary) system.

(MS) Medical Scribe Certification Practice Test