Skills Chapter 23 Patient History Quiz

Questions and Answers

What is an allergy?

Acquired hypersensitivity to a substance (allergen) that does not normally cause a reaction.

What does CHEDDAR stand for in charting?

Chief Complaint, History, Examination, Details of Problems and Complaints, Drugs and Dosages, Assessment, and Return Visit.

What is a chief complaint?

The specific reason, problem, or symptom that brought the patient to see the provider.

What is a clinical diagnosis?

Identification of a disease by history, laboratory studies, and symptoms. Signup and view all the answers

What does 'objective' refer to in a medical context?

A patient sign that is visible, palpable, or measurable by an observer. Signup and view all the answers

What is the Problem-Oriented Medical Record (POMR)?

A type of patient chart record keeping that uses a sheet at a prominent location in the chart to list vital identification data. Signup and view all the answers

What does SOAP/SOAPER stand for?

Subjective impressions, Objective clinical evidence, Assessment or diagnosis, Plans for treatment, Education for patient, and Response of patient to education and care given. Signup and view all the answers

What is a Source-Oriented Medical Record (SOMR)?

A type of patient chart record keeping that includes separate sections for different sources of patient information. Signup and view all the answers

What does 'subjective' mean in a medical context?

Symptom that is felt by the patient but is not observable by others. Signup and view all the answers

Study Notes

Definitions and Concepts in Patient History and Documentation

Allergy: Hypersensitivity reaction to a normally harmless substance, referred to as an allergen.
CHEDDAR: A detailed charting methodology encompassing:
- Chief Complaint
- History
- Examination
- Details of Problems and Complaints
- Drugs and Dosages
- Assessment
- Return Visit
Chief Complaint: The primary issue or symptom prompting a patient to seek medical attention.
Clinical Diagnosis: Determining a disease through patient history, laboratory tests, and observed symptoms.
Objective: Observable signs of a patient's condition that can be measured or seen by a healthcare provider.
Problem-Oriented Medical Record (POMR): A systematic record-keeping approach where vital patient identification data and medical problems are organized numerically for easy reference.
SOAP/SOAPER: Framework for documenting patient progress notes that includes:
- Subjective impressions from the patient
- Objective clinical findings
- Assessment or diagnostic conclusion
- Plans for treatment
- Education provided to the patient
- Patient's response to care and education
Source-Oriented Medical Record (SOMR): Record organization that categorizes patient information by source, such as lab reports and progress notes.
Subjective: Symptoms experienced by the patient that are not externally observable, relying on the patient's own account.

Description

Test your knowledge on patient history and documentation with this quiz based on Skills Chapter 23. From understanding allergies to the CHEDDAR charting approach, you'll reinforce your comprehension of essential medical terms and practices. Perfect for healthcare students and professionals alike.