Written Communication Final

Question 1

*Explain the importance of written

communication 5

Answer 1

1. Continuity of care
2. Legal protection
3. Reimbursement
4. Quality improvement
   o Identify a problem
   o Educating staff
   o Re-evaluation for resolution
5. Regulatory standards -(can be fined or lose
   certification of a facility)

Question 2

Demonstrate the 13 essential guidelines for

charting in a medical/dental record

Answer 2

1. Time
2. Abbreviations
3. Punctuation
4. Active Voice
5. Spelling
6. Concise
7. Specific
8. Write Legibly
9. Organization
10. Stick to the Facts
11. Sign and Date all Entries 12.Making Corrections 13.Making Late Entries

Question 3

If Used incorrectly, can lead to confusion,

errors, wrong dosages and incorrect tx

Answer 3

Abbreviations and Symbols

Question 4

Active Voice conveys a ___ and ___ portrayal of events. Start your sentence with a ___

Answer 4

natural
direct
verb

Question 5

Spelling incoorectly is unprofessional, lazy and poor judgment. Biggest concern is spelling ___ wrong

Answer 5

medications

Question 6

Is it better to be concise with chart notes or write a narrative

Answer 6

Concise

Question 7

Words that are vague can be misinterpreted
(disoriented or confused)
so be ___

Answer 7

Specific

Question 8

The purpose of a medical record
is to communicate information
between ______ ___ ____

Answer 8

health care providers

Question 9

Organize your chart note information in ____ order

Answer 9

chronological order

Question 10

Stick to the facts do not put your personal ____ or __ into charting… just state facts.

Answer 10

assumptions

bias

Question 11

You must ___ and date all entries

Answer 11

sign

Question 12

Making Corrections: Draw a single line through the error; the error should be legible and write “____entry”

Answer 12

mistaken

Question 13

What to do when making a late entry

Answer 13

Write “late entry” with a brief note stating why this information was not charted. Make the appropriate information and sign the entry

Question 14

What are the 5 NEVERS of documenting

Answer 14

1. Document for someone else
2. Ask someone else to document for you
3. Document false information
4. Delete, erase, scribble over or white out
5. Tamper with the medical record

Question 15

What are the 2 Charting Systems

Answer 15

PIE

SOAP

Question 16

PIE NOTES

Answer 16

-Problem (explanation of
the problem)

-Implementation (or
action taken)

-Evaluation (how the
patient feels now and
level of
comprehension of
teaching)

Question 17

SOAP Notes

Answer 17

-Subjective (what the
patient says) 
-Objective (what you
observed) 
-Assessment 
-Plan (what you plan to
do to correct the
problem)

Question 18

PACIFIC UNIVERSITY CHART NOTE

Answer 18

CHART
Concern (patient concerns) History (pertinent medical & dental hx alerts)
Assessments Recommendations Treatment provided
NV: plan for the next appointment
PARQ
Signature

Question 19

C in Chart note means

Answer 19

Concerns
A summary statement which includes the patient’s concern(s) and concerns from a referral source. • Why has the patient come today? • Patient was referred for dental cleaning by
physician

Question 20

H in Chart note means

Answer 20

Health and Dental History
• Start with ASA? State any systemic problems
that may require additional treatment
modifications (recent heart attack,
diabetes…) • State vital signs, elevated blood sugar levels,
AIC, clotting time, etc. • Include: Last dental visit or irregular dental
care

Question 21

A in CHART

Answer 21

Assessments

Include all assessments findings completed today. May include: • AAP • Oral hygiene status • PI/GI • Radiographic findings • Caries • Lesions • Risk Assessment • Gingival Descriptions

Question 22

R- CHART

Answer 22

Recommendations

• All recommendations given during this
appointment. 
• Recommended treatment 
• Oral hygiene instructions– include tool and
technique) 
• Referrals (to who, for what), 
• Premedication 
• Recare interval (# of months and time
needed) • Other?

Question 23

T in Chart

Answer 23

Treatment

Question 24

T in Chart

Answer 24

Treatment
• All recommendations given during this
appointment. • Recommended treatment • Oral hygiene instructions– include tool and
technique) • Referrals (to who, for what), • Premedication • Recare interval (# of months and time
needed) • Other?

Question 25

Chart note NEXT Visit should always include

Answer 25

OHI

Question 26

*** What does PARQ mean in CHART

Answer 26

P= Procedure 
A= Alternatives
R= Risks and Benefits
Q= Questions

Question 27

Consent form to be signed must include

Answer 27

– Problem
– Type of procedure
– Statement of risks and benefits
– Expected outcomes
– Agreement by the patient
– Cost (in our clinic)

Question 28

Telephone Communication document the following: Document the following

Answer 28

– Problem
– Type of procedure
– Statement of risks and benefits
– Expected outcomes
– Agreement by the patient
– Cost (in our clinic)

Question 29

Guidelines for Referrals: Communicate the following informations

Answer 29

• Type of services needed
• Prior services rendered
• Date services should begin • Goals of the service
• Specific instructions
• Include necessary radiographs, charts and
information

Question 30

C
O
N
S
U
L
T

Answer 30

Clarify terms you do not understand prior to
making the call

Objective data (pt name, age, contacts)

Necessary Past Hx

Symptoms/signs

Unusual Circumstances

Looking: what services the patient is looking to
obtain

Time: when you need services to start