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PATIENT ASSESSMENT EXAM 2 MCPHS EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED LATEST UPDATE
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PATIENT ASSESSMENT EXAM 2 MCPHS EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED LATEST UPDATE The medical record is a legal document, name 4 parties that are legally allowed to view it. 1- Court – Medical Legal document 2- Communication tool between providers 4- Health care paym...

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  • November 2, 2024
  • 56
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • patient assessment exam 2 mcphs exam questions and

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  • MCPHS
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PATIENT ASSESSMENT EXAM 2 MCPHS EXAM

QUESTIONS AND ANSWERS WITH COMPLETE

SOLUTIONS VERIFIED LATEST UPDATE


The medical record is a legal document, name 4 parties that are legally allowed to view it.


1- Court – Medical Legal document


2- Communication tool between providers


4- Health care payment determinations (coding and billing)


5- Quality control and research (education)


What does CMS stand for?


Centers for Medicare and Medicaid Services - the nations

largest payer for healthcare services.


Why do you need to confirm accurateness of reported services and validate site, necessity,

appropriateness of services provided?


audits / fraud


Who cannot legally access a medical record?


police and lawyers


The medical record establishes your _______________ as a health care provider

,establishes your credibility as a health care provider*


Identify general principles of documentation include


Brief notes during exam


Record ASAP


Avoid abbreviations


Document observations only and what a patient tells you, not your personal interpretations


Record expected and unexpected findings


Do not carry forward/ copy & paste


Why do you not carry forward/ copy & paste medical info?


-Can impact patient safety


-Can perpetuate erroneous or outdated information


-Can pose significant legal and regulatory challenges


What are the 4 types of notes?


Problem Focused


Expanded Problem Focused


Detailed


Comprehensive


Each type of NOTE includes some or all of the following elements (4)


1- Chief complaint (CC)

,2- History of present illness (HPI)


3- Review of systems (ROS)


4- Past, family, and/or social history (PFSH)


What is a problem focused note?


a limited examination of the affected body area or organ system. questions are directed at problem.


What is a Comprehensive note?


a general multi-system examination, or complete examination of a single organ system and other

symptomatic or related body area(s) or organ system(s).


When documenting a comprehensive note, which terms are used to describe the level of service for:


History of Presenting Illness (HPI)


Review of Systems (ROS)


Past, Family, and/or Social HX (PFSH)


Type of History


(HPI) Extended


(ROS) Complete


(PFSH)Complete


Type of History Comprehensive


What does SOAP stand for?


Subjective

, Objective


Assessment


Plan


Subjective means?


What the patent tells you, what you can see /hear


When is there an exception to not do a comprehensive SOAP note?


when a patient presents with an emergent need and initiating treatment is a higher priority


When can you do a Focused note?


-Established patients

-Routine or urgent care visits

-Addresses focused concerns (ankle sprain, finger laceration)


What components go in the SUBJECTIVE part of a SOAP note?


Patient ID info (verify)

Source of info (usually patient)

CC (chief concern)

HPI in paragraph (OLDCARTS)

PMH

Social History (SODAHTIMESS)

Family History

ROS (if it makes more sense to put this directly after the HPI, no one will fault you.)


What does OLDCARTS stand for?

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