types of medical records
documented numbered list of problems
POMR>>>Problem-Oriented Medical Record
The information in a POMR includes the following items: database; problem list; educational, diagnostic, and treatment plan; and progress notes.
The patient registration form contains...
among other information, an emergency contact name, relationship, and phone number.
"My right knee feels like it's full of fluid."
Client's Words
_____ the plan of action
The P section of SOAP documentation is ____.
The P, or Plan of action, section of SOAP documentation includes treatment options, chosen treatment, medications, tests, consultations, patient education, and follow-up.
One of the most important duties of a medical assistant....
fill out and maintain accurate and thorough patient records
Medical records are legal documents that contains...
- registration, history, physical, diagnostic testing, operative reports, diagnosis/treatment plans, correspondence
patient registration form
The completed registration form is the base document for each patient's financial record.
Filling out all of the forms in the pt.'s record & providing complete information when making a notation in the pt.'s chart.
Completeness
___data that comes from examination results and from the physician
The O section of SOAP documentation is ____.
The O, or Objective, section of SOAP documentation contains data from the physician, examinations, and test results.
charting/documentation errors
Draw a single line through the information to be deleted, making sure that the original entry is still legible.
SOAP means
Subjective, Objective, Assessment, Plan
Which of the following is necessary to release a patient's record to the patient's insurance company?
Patient's written consent
Brief and to the point.
Conciseness
___the diagnosis or impression of a patient's problem
The A section of SOAP documentation includes ___.
The A, or Assessment, section of SOAP documentation contains the diagnosis or impression of a patient's problem.
As the medical assistant, regarding documenting telephone encounters.....
Telephone calls must be recorded and dated, even if the physician did not reach the patient. State whether the physician got an answer, left a message on an answering machine or with a person, and so on.
conventional method of charting
SOMR>>> Source-Oriented Medical Record
The SOMR (sometimes called the conventional method) includes areas for data from the patient, treating physician, specialist, laboratory, hospital, or other locations to document in the record.
which form is used to verify that a patient understands treatment options and the risks associated with them.
Informed consent forms
Entries in the patient record are dated to show the order in which they are made.
Chronological order
____data that comes directly from the patient
The S section of SOAP documentation is ____.
The S section of SOAP documentation contains subjective data from the patient and includes the patient's description of his or her signs and symptoms, opinions, and comments.
what would not be included on a patient registration for?
Allergies would not be listed on the patient registration form. They would be listed on the patient's medical history.
CHEDDAR is
chief complaint, history, exam, details, drugs, assessment, return visit
Which of the following record types may be corrected or updated?
All documents in a medical record may be corrected and updated if the correct format is used.
Lab reports, Provider written notes,
Medical assistant’s written notes,
Patient medical history
Protecting the patient's privacy.
Confidentiality
Progress notes done in SOAP format
POMR charting
If a patient brings in test results from another physician, the MA should:
keep them with the chart and document the information.
Give to provider (to review during current appt. and also scan into pt.'s chart as office correspondence)