MT History & Physical Documentation 2 — Questions and Answers
Question 1: In an H&P, the term 'pertinent positive' refers to which of the following?
- A symptom the patient denies that rules out a diagnosis
- A finding that supports the working diagnosis (Correct answer)
- A lab result above normal range
- A medication the patient is currently taking
Correct answer: A finding that supports the working diagnosis
A pertinent positive is a symptom or sign present that supports or is consistent with the suspected diagnosis.
Question 2: Which section of the H&P documents the patient's previous surgeries and hospitalizations?
- Family History
- Social History
- Past Medical History (Correct answer)
- Review of Systems
Correct answer: Past Medical History
Past Medical History (PMH) includes prior illnesses, surgeries, hospitalizations, and significant medical events.
Question 3: The abbreviation 'HPI' in medical transcription stands for:
- History of Present Illness (Correct answer)
- Hospital Patient Index
- High Priority Imaging
- Health Provider Information
Correct answer: History of Present Illness
HPI stands for History of Present Illness, the narrative describing the patient's current complaint in detail.
Question 4: When transcribing the ROS, a physician states 'negative times ten.' What does this mean?
- Ten symptoms were found to be present
- Ten organ systems were reviewed and all findings were negative (Correct answer)
- The patient has ten current medications
- Ten prior diagnoses were documented
Correct answer: Ten organ systems were reviewed and all findings were negative
'Negative times ten' means all ten organ systems reviewed in the ROS were within normal limits or denied by the patient.
Question 5: Which of the following is the correct way to transcribe a physician's dictation of 'the patient denies SOB, CP, or palpitations'?
- The patient denies shortness of breath, chest pain, or palpitations. (Correct answer)
- The patient denies SOB, CP, or palpitations.
- The patient denied shortness-of-breath, chest-pain, or palpitations.
- The patient denies s.o.b., c.p., or palpitations.
Correct answer: The patient denies shortness of breath, chest pain, or palpitations.
Medical abbreviations in dictation should be expanded to their full terms in the transcribed document for clarity and compliance.
Question 6: In an H&P, 'gravida 3, para 2' is typically documented in which section for a female patient?
- Family History
- Past Medical History or OB/GYN History (Correct answer)
- Social History
- Chief Complaint
Correct answer: Past Medical History or OB/GYN History
Obstetric history including gravida/para status is documented in Past Medical History or a dedicated OB/GYN History subsection.
Question 7: The physical examination finding 'PERRL' stands for:
- Pupils equal, round, and reactive to light (Correct answer)
- Patient exhibits regular respiratory lung sounds
- Peripheral edema recorded, right leg
- Pulse equal, rate, rhythm, and level
Correct answer: Pupils equal, round, and reactive to light
PERRL means Pupils Equal, Round, and Reactive to Light, a standard finding documented in the HEENT portion of the physical exam.
MT History & Physical Documentation 2
In an H&P, the term 'pertinent positive' refers to which of the following?