MS Patient Assessment & Documentation 3

Question 1

When a scribe documents 'Pt c/o N/V x2 days,' what is the patient experiencing?

Accepted Answer

Nausea and vomiting for 2 days

Answer

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?

Accepted Answer

Vital Signs

Answer

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?

Accepted Answer

The patient's father had a heart attack at 55

Answer

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?

Accepted Answer

As needed

Answer

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?

Accepted Answer

Non-tender

Answer

NT in abdominal exam documentation stands for non-tender, indicating the patient did not experience pain on palpation.

(MS) Medical Scribe Certification Practice Test