SOAP
the P in SOAP documentation stands for
Plan
which document serves as the "base" for the patient patient medical record
the patient medical history form
which of the 6 C's means "getting to the point?"
conciseness
when children reach this age, most states consider them adults with the right to privacy regarding all their medical information
18
the "C" in CHEDDAR stands for
Chief Compliant
the S in SOAP documentation stands for
Subjective
which of the following are possible uses for patient medical records
research, quality of care, and patient education
the six C's of charting include
client's words, clarity, completeness, conciseness, chronological order, confidentiality
When you are in doubt regarding who is authorized to sign a release of records form for a minor
always ask your superior
the "H" in CHEDDAR stands for
History
the O in SOAP documentation stands for
Objective
the following patient details would be filed under "O" using the SOAP documentation method
BP 160/92
describe why it is so important to use care when making corrections to medical charts.
medical charts are legal documents, if changes are done incorrectly, it can jeopardize patient care and can become a legal problem for the physician
Test results received from sources outside the practice are best organized in sections within what part of the medical chart when utilizing the SOMR format?
based on the department the documents come from
the "E" in CHEDDAR stands for
Examination
which of the following elements of SOAP charting describes the data that come directly from the patient
S
which filing system uses the patient problem list as the source for filing within the patient medical record
POMR
list four additions that a provider might want to make to a patient's chart
labs, images, family history. details for visit, Rx, progress notes diagnosis, habits with tobacco/alcohol
as a general rule, if information is not documented what happens
no one can prove that an event or a procedure took place
the "R" in CHEDDAR stands for
Return visit information or referral, if applicable
which of the following elements of SOAP charting describes the course of treatment to be followed
P
the following documents from other sources frequently become part of the patient's medical record
x-rays, CT scans, MRI results, lab results from private labs or hospitals, hospital discharge summaries, hospital operative notes
explain the six C's of charting
"clients words" using the clients exact words. "clarity" use precise descriptions and accepted medical terminology. " completeness" fill out all the forms used in patient record "conciseness" brief and to the point "chronological order" records must be dated to show the order in which they are made "confidentiality" patient records are forms are confidential and is considered PHI
in a conventional, or source-oriented, medical record, all the patient's problems and treatments are recorded in the record in __ order.
reverse chronological order
the "Ds" in CHEDDAR stands for
Details of problem and complaint, Drugs and dosage