Chapter 8 - Medical Communication and Documentation

Question 1

What is SAILER used for and what does it stand for?

Answer 1

Essential communication content for OEC purposes.
S - Sex of the patient
A - Age of the patient
I - Incident/chief complaint
L - Location
E - Equipment needed
R - Resources needed

Question 2

What is a hand-off report?

Answer 2

An oral report given at the transfer of a patient from one provider to another.

Question 3

What does SOAP stand for?

Answer 3

S - Subjective: What the patient tells you, chief complaint, and history
O - Objective: What you find
A - Assessment: Your general impression
P - Plan: All aspects of treatment

Question 4

What is CHEATED used for and what does it represent?

Answer 4

Used for medical documentation
C - Chief complaint
H - History: SAMPLE
E - Examination
A - Assessment
T - Treatment
E - Evaluation
D - Disposition

Question 5

What does FACTUAL-OEC stand for?

Answer 5

F - Facts
A - Accurate
C - Complete
T - Terms
U - Unbiased
A - Avoid slang
L - Legible/legal
O - Organized
E - Error free
C - Checked

Question 6

What does the medical term capacity mean?

Answer 6

The patient has normal decision-making abilities and whose judgment is not impaired.