RECORDS MANAGEMENT

Question 1

POMR

Answer 1

problem-oriented medical record
(the history and physical exam database; a detailed patient problem list; an educational, diagnostic, and treatment plan; as well as the progress notes)

Question 2

SOAP approach

Answer 2

Subjective: this information comes from the patient describing their signs and symptoms; it is recommended that you use direct quotes or paraphrase the patient’s subjective comments about their status

Objective: this information comes from the health care provider’s observations and measurements including vital signs, examination results, and laboratory test results

Assessment: this information describes the diagnosis of the patient’s problem or what the provider believes is the condition facing the patient

Plan: this component of the documentation states action or steps that will be taken to address the patient’s problem; this includes recommended medications, treatment, consultations, patient’s education, and follow-up care. The plan should always be discussed with the patient prior the end of the office visit. In some cases, written instructions should be provided

Question 3

full block format

Answer 3

all content is aligned on the left side of the document

Question 4

modified block format

Answer 4

the date and the closing compliment are centered on the page. All other content is aligned on the left side of the document

Question 5

semi-block format

Answer 5

the date and the closing compliment are centered on the page. The start of each new paragraph in the body is indented five spaces to the right, but all other content not already specified is aligned on the left side of the document

Question 6

hanging indentation format

Answer 6

the date and the closing compliment are centered on the page. The first line of every paragraph in the body and other content not already specified is aligned on the left side of the document. The subsequent lines of every paragraph in the body are indented five spaces to the right.

Question 7

simplified format

Answer 7

all content is aligned on the left side of the document. However, this format does not include a greeting or a closing compliment.

Question 8

letter

Answer 8

1. heading
2. opening
3. body
4. closing

Question 9

memoranda (memo)

Answer 9

1. to
2. from
3. date
4. subject

Question 10

manuscripts

Answer 10

1. title page
2. acknowledgements
3. summary
4. text
5. references
6. footnotes
7. bibliography
8. graphic elements

Question 11

EHRs

Answer 11

electronic health records