A 10-year-old girl is brought to her regular pediatrician with a low-grade fever, nausea and fatigue. Her physician documents a brief HPI, Extended ROS, and pertinent PFSH. What is the overall history?
A. Problem-focused
B. Expanded problem-focused
C. Detailed
D. Comprehensive
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Q. 2) Which of the following BEST defines history?
A. Documentation of the patient's personal sensation of the current health complaint, the status and function of the patient's body, as well as past medical history, genetic medical history, and/or any social habits, which may impact the patient's health
B. Documentation of a collection of the patient's responses to questions related to their own health prior to the time of the visit, requiring verbal or written responses from the patient
C. Documentation of any of eight standardized descriptions with which the patient may provide a visceral, personalized description of the specific health issue, complaint or disease for which the patient came to the clinician
D. Documentation of the patient's past medical history, the medical history of the patient's family, and the patient's day-to-day social activities
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Q. 3) Physician documents a brief HPI, extended ROS, and pertinent PFSH for a new patient. What is the overall history level?
A. Problem-focused
B. Expanded problem-focused
C. Detailed
D. Comprehensive
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Q. 4) What are the levels of history?
A. None, Pertinent, Extended, Complete
B. Problem-focused, Expanded problem-focused, Detailed, Comprehensive
C. Brief, Extended
D. Pertinent, Extended
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Q. 5) A woman presents to her physician's clinic complaining of severe abdominal pain after an eight-year absence. Her physician documents an extended HPI, complete ROS, and a complete PFSH. What is the overall history level?
A. Problem-focused
B. Expanded problem-focused
C. Detailed
D. Comprehensive
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Q. 6) Which of the following BEST defines the history of present illness?
A. Documentation of any of eight standardized descriptions with which the patient may provide a visceral, personalized description of the specific health issue, complaint or disease for which the patient came to the clinician
B. Documentation of a collection of the patient's responses to questions related to their own health prior to the time of the visit, requiring verbal or written responses from the patient
C. Documentation of the patient's past medical history, the medical history of the patient's family, and the patient's day-to-day social activities
D. Documentation of the patient's personal sensation of the current health complaint, the status and function of the patient's body, as well as past medical history, genetic medical history, and/or any social habits, which may impact the patient's health
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Q. 7) Established patient presents to clinic today with painful right ear. No fever, chills, or sore throat reported. Patient does NOT smoke. What is the overall history level?
A. Problem-focused
B. Expanded problem-focused
C. Detailed
D. Comprehensive
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Q. 8) Physician documents a brief HPI, extended ROS, and pertinent PFSH on an established patient. What is the overall history level?
A. Problem-focused
B. Expanded problem-focused
C. Detailed
D. Comprehensive
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Q. 9) _______ what is the abbreviation for problem-focused history
Fill in the blank with correct word.
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Q. 10) _______ what is the term for the lowest level of documented history, requiring a brief HPI, no ROS, and no PFSH
Fill in the blank with correct word.
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