Medical Documentation
What does SOAP stand for in medical documentation?
Subjective, Objective, Assessment, Plan
What type of communication involves facial expressions, gestures, and body language?
Nonverbal communication
Which punctuation mark ends a declarative sentence?
Period
What organ pumps blood throughout the body?
Heart
What does tachy- mean?
Fast or rapid
What section of a SOAP note includes information reported by the patient?
Subjective
What communication technique involves giving full attention and demonstrating understanding?
Active listening
Which is correct: The patient was discharged or The patient were discharged?
The patient was discharged
What is the largest organ of the human body?
Skin
What does -itis indicate?
Inflammation
What is the primary purpose of documentating patient care?
To maintain an accurate record of care and support communication
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
What is wrong with: The nurse administration the medication, the patient felt better?
Comma splice
What part of the brain controls balance and coordination?
Cerebellum
What is the medical term for difficulty breathing?
Dyspnea
What type of information includes measurable findings such as blood pressure and temperature?
Objective data
What communication technique asks patients to explain instructions in their own words?
Teach-back method
Why should unnecessary medical jargon be avoided in patient instructions?
To improve patient understanding
What kidney structures filter blood to begin urine formation?
Glomeruli
What does hepatomegaly mean?
Enlargement of the liver
What is the term for making a correction to a medical record while preserving the original entry?
An amendment or addendum
What is clear, respectful, confident communication without aggression called?
Assertive communication
What grammatical error occurs in: After reviewing the chart, the medication was administered by the nurse?
Dangling modifier
What process maintains a stable Internet environment?
Homeostasis
What is the term for a low platelet count?
Thrombocytopenia