MT History & Physical Documentation 3 — Questions and Answers
Question 1: Which of the following best describes the 'chief complaint' in an H&P?
- A detailed description of all past illnesses
- A brief statement of the patient's primary reason for the visit, often in the patient's own words (Correct answer)
- The physician's assessment of the patient's condition
- A list of all current medications
Correct answer: A brief statement of the patient's primary reason for the visit, often in the patient's own words
The chief complaint is a concise statement, often quoted directly from the patient, describing the main reason for seeking care.
Question 2: When a physician dictates 'the patient is a well-developed, well-nourished male in no acute distress,' this phrase belongs in which section?
- Chief Complaint
- Review of Systems
- General Appearance under Physical Examination (Correct answer)
- Assessment
Correct answer: General Appearance under Physical Examination
General appearance is the opening statement of the Physical Examination section describing the patient's overall presentation.
Question 3: The 'OLDCART' mnemonic used in taking the history of present illness stands for onset, location, duration, character, alleviating factors, relieving factors, and:
- Timing (Correct answer)
- Treatment
- Temperature
- Tolerance
Correct answer: Timing
OLDCART stands for Onset, Location, Duration, Character, Alleviating factors, Relieving factors, and Timing.
Question 4: In medical transcription, a 'pertinent negative' in the ROS means:
- A symptom the patient confirms is present
- A symptom denied by the patient that is clinically relevant to rule out a diagnosis (Correct answer)
- A lab value that is below normal
- A medication with no therapeutic effect
Correct answer: A symptom denied by the patient that is clinically relevant to rule out a diagnosis
A pertinent negative is a symptom the patient does not have that is important to note because its absence helps narrow the differential diagnosis.
Question 5: When transcribing vital signs dictated as 'BP 120 over 80,' the correct transcribed format is:
- BP 120/80 (Correct answer)
- BP 120-80
- BP 120 mmHg over 80 mmHg
- BP: one hundred twenty over eighty
Correct answer: BP 120/80
Blood pressure is standardly transcribed as systolic/diastolic using a forward slash, e.g., 120/80.
Question 6: Which of the following elements is NOT typically included in the Social History section of an H&P?
- Tobacco use
- Alcohol consumption
- Previous hospitalizations (Correct answer)
- Occupational history
Correct answer: Previous hospitalizations
Previous hospitalizations are documented in the Past Medical History, not Social History; Social History covers lifestyle and environmental factors.
Question 7: A physician dictates 'the abdomen is soft, nontender, nondistended with normoactive bowel sounds.' This is documented under:
- Review of Systems — Gastrointestinal
- Physical Examination — Abdomen (Correct answer)
- Assessment and Plan
- History of Present Illness
Correct answer: Physical Examination — Abdomen
Objective findings from the physician's hands-on examination of the abdomen are recorded under Physical Examination.
MT History & Physical Documentation 3
Which of the following best describes the 'chief complaint' in an H&P?