MT History & Physical Documentation 3

Question 1

Which of the following best describes the 'chief complaint' in an H&P?

Accepted Answer

A brief statement of the patient's primary reason for the visit, often in the patient's own words

Answer

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?

Accepted Answer

General Appearance under Physical Examination

Answer

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:

Accepted Answer

Timing

Answer

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:

Accepted Answer

A symptom denied by the patient that is clinically relevant to rule out a diagnosis

Answer

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:

Accepted Answer

BP 120/80

Answer

Blood pressure is standardly transcribed as systolic/diastolic using a forward slash, e.g., 120/80.

(MT) Certified Medical Transcription Practice Test

(MT) Certified Medical Transcription Practice Test

MT History & Physical Documentation 3