Chapter 22 Flashcards
(20 cards)
Which of the following is the most appropriate action in order to make a correction when an error has been made in the paper chart?
Draw a singal line thru the error, then write the correct entry and initial and date.
Which of the following is the most appropriate action in order to make a correction when an error has been made in the EMR?
Create an addendum, correcting the error
Which of the following is not a method used for charting?
SWISS
Information such as the patient’s full name, address and phone number would be found on what form?
Demographic data form
Which part of the medical history includes notes about location, quality and timing.
history of present illness
Which review of systems would include joint stiffness, muscle pain, and limited range of motion?
Musculoskeletal
Which review of systems would include SOA
Respiratory
Which of the following describes the physician’s overall assessment of major body functions?
Review of systems
NPO :
nothing by mouth
dx
diagnosis
prn
as needed
a triangle symbol :
change
symptoms and patient’s complaints :
subjective
diagnosis
assesment
further testing and treatment :
plan
vital signs :
objective
expansion of the information that brought the patient to the office :
history of present illness
all health problems, illnesses, and surgeries :
medical history
medical problems of siblings and parents :
family history
occupation, hobbies, and drug habits :
social history
