Documentation Flashcards
(6 cards)
1
Q
General guidelines for documentation
A
- Required for every visit/encounter (even phone calls)
- Must comply with/ applicable jurisdictional/regulatory requirements.
-In ink and w/ original signatures (electronic is okay)
-Errors should be corrected
-Should include notes of no shows and cancellations
2
Q
Types of documentation
A
Initial evaluation
Visit/encounter/daily
Reexamination
Discharge summary
3
Q
Components of an initial examination
A
History (part of examination)
Systems review (part of examination)
Tests and measures (part of examination
Evaluation
Diagnosis
Prognosis
Plan of care
4
Q
What are some compontnets of history
A
general demographics
Employment
Living environment
Family history
Medial/surgical history
Medications
Activity Level
5
Q
Components of a plan of care
A
Goals stated in measureable terms
Interventions to be used
Duration and frequency
Anticitpated discharge plans
6
Q
SOAP note
A
Subjective (what you hear)
Objective (what you observe and do)
Assessment (what you think)
Plan (what you will do)
