Clinical Documentation Flashcards

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1
Q

What are two document formats used for medical records?

A

Source-Oriented Medical Record and Problem-Oriented Medical Record.

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2
Q

What method helps with charting on medical records?

A

SOAP method of documentation.

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3
Q

SOAP stands for?

A

Subjective, objective, assess, plans

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4
Q

SBAR tool is used for what?

A

Effective documentation method utilized among healthcare professionals.

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5
Q

What does SBAR stand for?

A

Situation, background, assessment, recommendation

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6
Q
A
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