MT History & Physical Documentation 2

Question 1

In an H&P, the term 'pertinent positive' refers to which of the following?

Accepted Answer

A finding that supports the working diagnosis

Answer

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?

Accepted Answer

Past Medical History

Answer

Past Medical History (PMH) includes prior illnesses, surgeries, hospitalizations, and significant medical events.

Question 3

The abbreviation 'HPI' in medical transcription stands for:

Accepted Answer

History of Present Illness

Answer

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?

Accepted Answer

Ten organ systems were reviewed and all findings were negative

Answer

'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'?

Accepted Answer

The patient denies shortness of breath, chest pain, or palpitations.

Answer

Medical abbreviations in dictation should be expanded to their full terms in the transcribed document for clarity and compliance.

(MT) Certified Medical Transcription Practice Test