Documentation in Healthcare

1.     SOAP refers to

• a.    A method of documentation used in medical records

• b.    A procedure for making medical appointments

• c.     A bookkeeping system used in medical offices

• d.    A filing system used in medical offices

2.     Which of the following concerns have healthcare providers stated about the use of electronic health records and the required data entry they must complete?

• a.    They prefer the handwritten entry

• b.    It is confusing to use electronic records

• c.     It interferes with patient communications during the encounter

• d.    It is impersonal

3. Informed consent involves understanding which of the following?

• a.    Benefits of treatment

• b.    Purpose of treatment

• c.     Risks of treatment

• d.    All of the above

4. Generally, if information is not documented

• a.    It is not important

• b.    It cannot be proven that an event or procedure took place

• c.     Malpractice will occur

• d.    It is illegal

5.     Which of the following was not a reason for the development and usage of electronic health records?

• a.    Rising healthcare costs

• b.    An increase in medical errors

• c.     The increasing age of the general population

• d.    Increasing need for coordination of care

6.     The “S” in SOAP documentation refers to

• a.     Information provided by lab tests

• b.     Data that comes directly from the patient

• c.      Data that comes from the physician’s exam

• d.     The plan of action

7.     Who should correct an error in a patient’s chart?

• a. The person who originally charted the entry

• b.    The medical records manager

• c. The physician for the patient

• d. The charge nurse

8.     When using the problem-oriented medical record (POMR) formation, a patient’s abnormal hematocrit level would be recorded under which of the following?

• a.    Database

• b.    Treatment plan

• c.     Subjective information

• d.    Problem list

9.     Which of the following is one of the six C’s of charting?

• a.    Clerical

• b.    Client’s words

• c.     Consultation

• d.    Choice

10.      When adding laboratory results to a patient’s medical record,

• a.    You should leave them on the desk for the secretary to file

• b.    You should call the patient to review the results with them

• c.     You should verify that the physician has signed or initialed all reports before they are filed

• d.    Photocopy results and mail a copy to the patient