documentation

Question 1

Aid clinician in making diagnoses
Transfer of patient info to other members of the health care team
Repository of patient information for future clinical use

Answer 1

medical functions of medical chart

Question 2

The chart demonstrates the amount of medical “work” the patient received

Answer 2

billing

Question 3

3 functions of medical chart

Answer 3

1. medical functions
2. billing
3. legal document

Question 4

goal of medical charting

Answer 4

telling pt story in a clear, complete, and concise way

Question 5

sentence structure to use

Answer 5

simple. get to the point

Question 6

voice to use

Answer 6

active/present tense

Question 7

general medical record guidlines

Answer 7

accuracy
brevity-concise
clarity
punctuation
if written- strike through with one line, initial and date above

Question 8

c with line over

Answer 8

with

Question 9

s with line over

Answer 9

without

Question 10

styles of documents

Answer 10

narrative- mini paragraph
telegraphic- bullet point

Question 11

progress notes

Answer 11

soap notes

Question 12

components of outpatient medical record- full comprehensive

Answer 12

Identifying Data – on each page (Patient: name, sex/gender, ethnicity, dob/age, medical record number
Clinician name, date
Is present at top/start of EVERY page)
Patient Info
Problem List
Comprehensive health history
Complete physical exam
Assessment and plan
Progress notes
Labs
Imaging
Consult letters
Misc

Question 13

An index or table of contents that provides an overview of all of the patient’s problems.
Components may include
Diagnoses
Symptoms
Abnormal lab results
Personal/social/economical difficulties
Risk factors
Other crucial long-term factors
Components must be designated as active or resolved/inactive

Answer 13

the problem list

Question 14

tells us who is giving us the information- pt or pt parent etc

Answer 14

source/reliability of hx

Question 15

cc is a

Answer 15

prose statement

Question 16

hpi is a

Answer 16

narrative

Question 17

ros is done in

Answer 17

outline for

Question 18

always document in what order

Answer 18

head to toe

Question 19

for each body system, document in standard order by subsections for how exam is done

Answer 19

**Document in standard order (by subsections) for how exam is done – INSPECTION then PALPATION/PERCUSSION then AUSCULTATION – then OTHER/SPECIAL TESTS
List + findings first within each subsection for each system
may use images/charts/diagrams

Question 20

PE exam order

Answer 20

Vital Signs
General Statement
Skin/Hair/Nails
HEENT (Head-Eyes-Ears-Nose/Sinues-Mouth/Throat-Neck)
Cardiovascular
Pulmonary
Breast (if patient is female)
Abdomen
GU/Pelvic/Rectal
Musculoskeletal**
Neuropsychiatric**

Answer 21

assessment

Answer 22

plan

Question 23

general info for documenting a confirmed diagnosis

Answer 23

New or established diagnosis
Status – controlled, uncontrolled, worsening, improving
Treatment goal
Evaluation or surveillance
Management
Disposition

Question 24

general info in documenting an unconfirmed diagnosis-sx based

Answer 24

Suspected diagnosis
Rationale
Evaluation (to confirm)
Management
Less likely diagnoses
Rationale
Evaluation (to rule out)
Disposition

Question 25

each problem should include

Answer 25

assessment and plan

Question 26

s

Answer 26

subjective

Question 27

o

Answer 27

objective

Question 28

a

Answer 28

assessment

Question 29

p

Answer 29

plan

Question 30

e

Answer 30

education

Question 31

r

Answer 31

return to clinic

Question 32

What the pt tells you and/or the pt’s response to questions about their current physical condition. In other words this is the patient history BUT it is NOT comprehensive! The “S” only includes pertinent information Why is the patient here? Describe the problem(s) CONCISELY – only PERTINENT data

Answer 32

SOAPER

Question 33

3 things that are always pertinent in soaper notes

Answer 33

vital general heart and lungs

Question 34

Patient’s active then chronic stable problems May be noted as a confirmed diagnosis or an unconfirmed diagnosis ONLY the diagnoses addressed at THIS visit get listed

Answer 34

assessment

Question 35

Outpatient visits – overall plan (compared to max daily for inpatient) Diagnostic work-up, Consultations/Referrals, Prescription meds, Other prescribed Tx All MUST include the “ER” components as well!

Answer 35

plan

Question 36

5 ws and h

Answer 36

who-pt what-reason for encounter when where why how