SOAP Note Documentation
What does SOAP stand for?
Subjective, Objective, Assessment, Plan
What does EHR stand for?
Electronic Health Record
Teaching using verbal instructions and written materials is called what?
Factual teaching
Which required form gives consent to release health information?
HIPAA Release Form
Who handles this type of call is for rearranging patient visits?
MA
Which part of SOAP includes measurable data like vitals?
Objective
Name one advantage of an EHR over paper charts.
No lost paper files
Showing a patient how to use an inhaler before you send them home is called?
Modeling
Which document verifies insurance coverage?
Insurance Form
A patient wants to know their lab result. What type of call and who handles if positive or abnormal?
Doctor
A patient says, “My knee has been hurting for 2 weeks.” Which section does this go in?
Subjective
What tool in the EHR helps prevent medication errors by checking allergies/interactions?
Modeling and then asking the patient to test their own blood glucose while the MA observes is what method?
Return demonstration
Which paperwork collects medical history and current medications?
Health History Form
Who handles a patient is calling about a bill they received in the mail?
Billing Department
A provider orders an X-ray and rest with follow-up in a week. Where does this belong?
Plan
The term for the minimum standards to exchange PHI with clinicians and insurance companies
Meaningful Use
Having diabetic patients touch insulin pens and meter supplies is what method?
Sensory Teaching
What is the form patients sign that acknowledges financial responsibilities?
Financial Agreement or Practice Billing Policy
How do you handle a call from a patient with difficulty breathing?
911
Type 2 Diabetes
Assessment
What is the EMR called when it is transferred to outside health facilities?
EHR
Factual teaching is part of which domain?
Cognitive
Which form highlights how a patient's PHI will be handled by the practice
The NPP
Patient with rash on stomach should be scheduled when?
Try to schedule same day or transfer to nurse triage