Patient Documentation Unit Review

If the patient has difficulty with English, the MA should

• make appointment then make sure interpreter is present
• make appt after contacting interpreter
• speak loudly so pt will understand
• suggest the pt find a provider that speaks their language

A helpful question to ask a returning patient is (think follow up care)

• are you feeling bad today?
• didn't you get better with the treatment from the last visit?
• have you noticed any changes since your last visit?
• do you realize you gained 6lbs since your last visit?

When a pt reports not feeling well, the MA should respond by doing what?

• mark CC as "pt not feeling well"
• ask helpful questions to help pt express specific details
• pin down symptoms by guessing what the problem could be
• let the provider work with the pt

Source-oriented Medical Records (SOMR) are

• chronologic notes beginning with most recent visit

• have four major components

• are the best for finding information quickly

• are best when many providers see the same pt

Name, address, telephone numbers, birth date, social security number, insurance information, and person to contact in ER is known as

• Demographic data

• CCR or patient information

• Social history

• none of the above

Chief complaint is

• is abbreviated CC and contains Subjective data

• is a statement of objective findings made by the MA

• is objective data stated by the patient

• is all the complaints about the medical office from patients

Interviewing patients for medical history requires:

• special credentials such as CCMA or RMA
• cross-cultural interviewing and communication skills
• computer skills in medical note taking
• a major portion of receptionist time and energy

SOAP notes include

• medical history and results of lab tests

• only the providers plan for treating the patient

• Subjective and Objective information, assessments, and a plan for the patient

• only the MA's interactions with the patient

Subjective, Objective, Assessment, and Plan charting is sometimes referred to as:

• SOAP
• POMR
• SOMR
• CCRP

What is usually contained in the 1st part of the medical hx?

• Personality

• Chief Complaint (CC)

• Cause of illness

• Mental Status