Intro to Documentation

Question 1

This should be in the patient’s own words

Answer 1

CC = Chief Complaint

Question 2

Sections of the Chart note

Answer 2

Chief complaint
HPI
PMH, FH, SH
ROS
Physical Exam
Vitals
Assessments
Plan

Question 3

Make sure your notes are:

Answer 3

Clear - Reduce potential ambiguity and confusion. Also, the organization and order is helpful and not distracting.
Congenial - Document things in a professional and unbiased way
Complete/Comprehensive - Nothing important is missing
Correct - Quality, honest, and accurate information
Concise - Include only what is actually needed in the chart
Concurrent - Capture the important information before it becomes forgotten

Question 4

Avoid grammatical and spelling errors that might confuse the reader. When possible, _____ through your charts before signing them

Answer 4

re-read

Question 5

“Use non-judgemental language to describe your findings and evaluation” is an example of

Answer 5

Congenial chart noting

Question 6

“Spell out the supporting evidence for each problem or diagnosis. Your diagnosis is on trial” is an example of ___

Answer 6

completeness in chart noting

Question 7

“Include only what is actually needed in the chart” is an example of

Answer 7

conciseness in charting

Question 8

“Capture important information before you forget it!” is an example of

Answer 8

concurrent chart noting

Question 9

“Ensure you have quality, honest, and accurate information” is an example of

Answer 9

Correct chart noting

Question 10

Ensuring pertinent negatives are documented is part of what charting necessity?

Answer 10

Completeness