WEEK 2- Medical Documentation

Question 1

If you didnt write it down…

Answer 1

it didnt happen!!!!!!!

Question 2

SOAP documentation arranges progress notes according to

Answer 2

Subjective. Objective. Assesment. Plan

Question 3

Medical records are filed in what order?

Answer 3

Reverse chronological (newest to oldest)

Question 4

SOAP- chief complaint

Answer 4

Subjective

Question 5

SOAP- measurable data; vital signs; lab results; measurements

Answer 5

Objective

Question 6

SOAP- medical diagnosis

Answer 6

Assessment

Question 7

SOAP- ____for treatment

Answer 7

plan

Question 8

expands on SOAP format

Answer 8

CHEDDAR

Question 9

6 C’s of Charting

Answer 9

Client’s words, clarity, completeness, conciseness, chronological order. confidentiality

Question 10

first document found in a patient’s financial record is

Answer 10

patient registration form

Question 11

Possible uses for patient medical records

Answer 11

research, quality of care , and patient education

Question 12

MA should use what color ink

Answer 12

Black or Blue

Question 13

patient who does not follow medical advice he or she recevies

Answer 13

noncompliant patient

Question 14

diet, exercise, smoking, alcohol use, and drug use

Answer 14

social history

Question 15

creating & preparing medical records where info is grouped by type of record

Answer 15

SOMR- Source Oriented Medical Records

Question 16

Which insurance term is the amount of money paid out of pocket before insurance carrier begins paying?

Answer 16

Deductible

Question 17

Which type of delivery model or. plan are patients required to obtain referrals to specialists?

Answer 17

HMO