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
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
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
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
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
the "Ds" in CHEDDAR stands for
Details of problem and complaint, Drugs and dosage