MS Patient Assessment & Documentation 3 — Questions and Answers
Question 1: When a scribe documents 'Pt c/o N/V x2 days,' what is the patient experiencing?
- Neck pain and vomiting for 2 weeks
- Nausea and vomiting for 2 days (Correct answer)
- Nocturia and vertigo for 2 days
- Numbness and vision changes for 2 days
Correct answer: Nausea and vomiting for 2 days
N/V is the abbreviation for nausea and vomiting, and 'x2 days' indicates the symptom duration.
Question 2: Which section of the physical exam documents findings such as heart rate, blood pressure, temperature, and respiratory rate?
- Chief Complaint
- Review of Systems
- Vital Signs (Correct answer)
- Pertinent History
Correct answer: Vital Signs
Vital signs are the measured physiologic parameters including HR, BP, temperature, RR, and oxygen saturation.
Question 3: A patient's chart notes 'FH: Father with MI at age 55.' What does this mean for documentation purposes?
- The patient had an MI at age 55
- The patient's father had a heart attack at 55 (Correct answer)
- The patient has a family history of hyperlipidemia
- The patient's father is currently hospitalized
Correct answer: The patient's father had a heart attack at 55
FH stands for Family History, and MI is myocardial infarction (heart attack); this documents the father's cardiac event.
Question 4: What does 'PRN' mean in medication documentation?
- Per renal nutrition
- As needed (Correct answer)
- Prior to nursing evaluation
- Prescribed routine nightly
Correct answer: As needed
PRN is a Latin abbreviation for 'pro re nata,' meaning as needed or as the situation demands.
Question 5: A physician performs an abdominal exam and documents 'soft, NT, ND, NABS.' What does 'NT' indicate?
- Normal tone
- Non-tender (Correct answer)
- No tenderness to percussion
- Neurologically tested
Correct answer: Non-tender
NT in abdominal exam documentation stands for non-tender, indicating the patient did not experience pain on palpation.
Question 6: In medical documentation, 'Hx' is the standard abbreviation for:
- Hypoxia
- History (Correct answer)
- Hypertension
- Hexadecimal notation
Correct answer: History
'Hx' is universally used in medical records as an abbreviation for history.
Question 7: When documenting a psychiatric patient's mental status exam, the scribe notes 'thought process: linear and goal-directed.' This means the patient:
- Has paranoid ideations
- Is thinking logically and coherently (Correct answer)
- Is unable to follow commands
- Displays disorganized thinking
Correct answer: Is thinking logically and coherently
Linear and goal-directed thought process means the patient's thinking is organized, logical, and stays on topic.
MS Patient Assessment & Documentation 3
When a scribe documents 'Pt c/o N/V x2 days,' what is the patient experiencing?