Clinical Documentation Flashcards
1
Q
What are two document formats used for medical records?
A
Source-Oriented Medical Record and Problem-Oriented Medical Record.
2
Q
What method helps with charting on medical records?
A
SOAP method of documentation.
3
Q
SOAP stands for?
A
Subjective, objective, assess, plans
4
Q
SBAR tool is used for what?
A
Effective documentation method utilized among healthcare professionals.
5
Q
What does SBAR stand for?
A
Situation, background, assessment, recommendation
6
Q
A
