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Health Administration & Professional Responsibility > Documentation > Flashcards

Documentation Flashcards

1
Q

What does S.O.A.P stand for?

A

Subjective
Objective
Assessment
Plan

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2
Q

What does “Subjective” mean?

A

What the patient tells you?

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3
Q

What does “Objective” mean?

A

Observes and measures

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4
Q

What does “Assessment” mean?

A

Diagnosis

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5
Q

What does “Plan” mean?

A

Plan to get better

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6
Q

What is “Focus Charting”?

A

Focusing on patient strengths

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7
Q

What does F-DAR stand for?

A

Data
Action
Response

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8
Q

What is “POMR” stand for?

A

Problem Oriented medical record

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9
Q

What is “POMR”?

A

Comprehensive way of accessing patient medical history

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10
Q

What is “Narrative Charting”?

A

Record patient status and plan future treatment.

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11
Q

What does “HIPS” stand for?

A

History
Inspection
Palpation
Special Test

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12
Q

What does “HOPS” stand for?

A

History
Observation
Palpation
Special Test

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13
Q

Where must an athletes medical record be housed?

A

Confidential and secure location

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14
Q

What document must be signed by the patient explaining the risk, anticipated outcome, and alternatives of rehabilitation treatment?

A

Informed consent

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15
Q

What medical record keeping dictates notation only when process deviates from norms?

A

Charting by exception

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16
Q

What written document specifies standard of care during an emergency?

A

Emergency health plan

17
Q

What signed release from a patient waives all future legal claims against a health care worker or institution?

A

Exculpatory clause

18
Q

What is the scientific study of human work?

A

Ergonomics

Health Administration & Professional Responsibility (9 decks)

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