Making
What dos ROS mean
A systematic review of systems
What is the proper way to sign a charting entry?
D. Bennett, CMA
A review of the health status of blood relatives is known as
Family history
The name of the surgical procedure, description of procedure used during surgery, and postoperative diagnosis are all included in the ________report
Operative
The acronym for the format used to organize POR progress note is??
SOAP
_____________ is the term used to describe the process of making written entries about a patient in the medical record?
Charting
Why do we never erase or obliterate entries in a medical record?
Credibility is reduced if the physician is involves in litigation
What is an example of a familial disease?
Diabetes mellitus
Which report consists of an account of significant events of a patient's hospitalization?
Discharge summary report
In a source oriented record, a radiology report is filed under which chart tab?
Lab/X-ray
Why should we use black ink when charting in patients chart?
To provide a permanent record
An expansion of the chief complaint is called?
Present illness
Social history is important because a patient's____________________ may affect their condition.
Lifestyle
Which report consists of macroscopic and microscopic descriptions of tissue removed during surgery?
Pathology report
The physician's interpretation of the patient's condition is recorded in POR progress notes under???
Assessment
T or F When charting, the patient's name should be at the beginning of each entry?
False
The patient's previous diseases, injuries, and operations is know as?
Medical history
Dietary history, health habits, and occupation are all included in the __________ history
Social
A copy of the patient's emergency department report is sent to____________???
Data obtained from the patient is recorded in POR progress note under???
Subjective data
Why should we chart immediately after performing a procedure?
To avoid forgetting certain aspects of the procedure
Medical history includes all of the following EXCEPT ,accidents and injuries, immunizations, operations, medications, or occupation
Occupation
Conclusions drawn from the interpretation of data are known as
Medical impressions
When is a consent to treatment form required?
Sebaceous cyst removal
What is reverse chronological order?
Most recent placed in front of other documents