When recording assessments during the construction of the problem-oriented medical record, the examiner should: Response Feedback: Once the examiner has a list of problems constructed, then an assessm... ent is made for each unique problem. • Question 2 What finding is unique to the documentation of a physical examination of an infant? Response Feedback: The size & characteristic of the fontanel are unique & important in the assessment of an infant. Data on liver span, prostate size, thyroid position, & visual acuity are adult assessment findings. • Question 3 The quality of a symptom, such as pain, is subjective information that should be: Response Feedback: Pain is subjective & only the patient can rate the perceived severity. Pain, therefore, should be recorded the history using a 1-to-10 scale. • Question 4 When communicating with older children & teenagers, you should be sensitive to their: Response Feedback: Adolescents are usually reluctant to talk; therefore, the provider should clearly communicate a respect for their confidentiality. • Question 5 J.M. has been seen in your clinic for 5 years. She presents today with signs & symptoms of acute sinusitis. The type of history that is warranted is a(n) _____ history. Response Feedback: If the patient is well known or if you have been seeing the patient for the same problem over time, a focused history is appropriate. • Question 6 An example of a complementary care modality is: [Show More]
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