Which of the following observations should not be included in a patient's medical record?
A. notes regarding reaction to anesthesia
B. change of marital status
C. change in weight
D. notes regarding patient's participation in a rally
E. notes regarding patient's reaction to a new prescription
D. notes regarding patient's participation in a rally
All notes in the medical record should be pertinent to the patient's care. His or her participation in a rally is not related to care.
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Shingles infections only occur in people who have previously had:
A. chickenpox. B. hepatitis B. C. MRSA. D. AIDS.
Your OEC class asks you to describe the term behavior. Which of the following statements would be the correct response?
a. What is acceptable behavior in one community may not be acceptable in another. b. Behavior pertains to how you perform a physical activity only. c. Meditation is the absence of behavior. d. Yelling is never an acceptable behavior.
Which of the following contains a comprehensive summary of CPT additions, deletions, and revisions since last year?
a. Appendix A b. Appendix B c. Appendix D d. Appendix F
Which of the following is the MOST proper, concise way to enter the following information into a patient's medical record?
"Patient comes into the office today complaining of a headache that has lasted for the past three days. Patient states the pain is constant and is described as throbbing and pulsating. Patient is visibly uncomfortable and rates his pain 8 out of 10." A. "Patient has a headache. Patient says her head is throbbing. Patient is whining and complaining that it hurts badly". B. "Patient presents with a headache x 3 days, describing it as constant throbbing and pulsating". Patient appears uncomfortable and rates pain 8/10." C. The patient comes into the office today with the complaint of a headache. The headache has lasted three days. The patient has described the headache pain as throbbing and pulsating. The patient states the headache pain is constant. The patient is very uncomfortable today due to the headache pain. The patient has rated the level of headache pain 8 out of 10 on the pain scale." D. "Complains of throbbing headache. 8/10." E. Headache. Three days. Throbbing. Constant. Uncomfortable. 8/10.