UTC Patient Assessment & Documentation 3 — Questions and Answers
Question 1: Which of the following best describes the purpose of obtaining informed consent before a sonographically guided biopsy?
- To fulfill billing requirements only
- To ensure the patient understands the procedure, risks, and alternatives (Correct answer)
- To allow the sonographer to perform the procedure independently
- To record the patient's insurance provider
Correct answer: To ensure the patient understands the procedure, risks, and alternatives
Informed consent ensures the patient has been educated about the procedure, potential complications, and alternative options before agreeing to proceed.
Question 2: A patient undergoing a thyroid ultrasound reports hoarseness and difficulty swallowing. How should the sonographer respond?
- Ignore these symptoms as they are unrelated to thyroid imaging
- Document the symptoms and communicate them to the interpreting physician (Correct answer)
- Advise the patient to see an ENT instead
- Complete only half of the exam and reschedule
Correct answer: Document the symptoms and communicate them to the interpreting physician
Hoarseness and dysphagia can indicate mass effect from a thyroid lesion on adjacent structures and must be documented and reported to the interpreting physician.
Question 3: What does SOAP stand for in the context of patient documentation?
- Subjective, Objective, Assessment, Plan (Correct answer)
- Sonographic, Observation, Analysis, Protocol
- Systematic, Organized, Anatomical, Procedural
- Standard, Optimized, Accurate, Practical
Correct answer: Subjective, Objective, Assessment, Plan
SOAP is a widely used medical documentation format: Subjective (patient's complaint), Objective (findings), Assessment (diagnosis), and Plan (treatment).
Question 4: A pediatric patient is brought in for an abdominal ultrasound by a non-custodial grandparent. Who must provide consent for the examination?
- The grandparent if they accompanied the child
- A legal guardian or custodial parent (Correct answer)
- The child, if old enough to verbally agree
- The ordering physician
Correct answer: A legal guardian or custodial parent
For minors, informed consent must be obtained from a legal guardian or custodial parent; a non-custodial relative does not have legal authority to consent.
Question 5: When assessing a patient with suspected appendicitis, which symptom pattern is most classically documented?
- Pain starting in the epigastrium migrating to the right lower quadrant with rebound tenderness (Correct answer)
- Left flank pain radiating to the groin
- Diffuse abdominal pain relieved by eating
- Right upper quadrant pain after fatty meals
Correct answer: Pain starting in the epigastrium migrating to the right lower quadrant with rebound tenderness
Classic appendicitis presents as periumbilical or epigastric pain migrating to McBurney's point in the right lower quadrant, often with rebound tenderness.
Question 6: Which notation in a patient's medical record would indicate that prior imaging studies are available for comparison?
- PMH (past medical history) section noting prior exams (Correct answer)
- The patient's medication list
- The referral source's address
- The scheduling department's intake form
Correct answer: PMH (past medical history) section noting prior exams
Prior imaging is typically noted in the patient's PMH or clinical history section, allowing the sonographer and interpreter to request comparison studies.
Question 7: A pregnant patient at 28 weeks gestation presents for a growth ultrasound with a fetal heart rate of 95 bpm measured on the monitor. What is the appropriate response?
- Continue the exam and note the FHR in the report
- Document and immediately notify the supervising physician of possible fetal bradycardia (Correct answer)
- Reassure the patient and proceed without documentation
- Reschedule the exam for the next day
Correct answer: Document and immediately notify the supervising physician of possible fetal bradycardia
Normal fetal heart rate is 110–160 bpm; a rate of 95 bpm constitutes bradycardia and requires immediate physician notification.
UTC Patient Assessment & Documentation 3
Which of the following best describes the purpose of obtaining informed consent before a sonographically guided biopsy?