Documentation Standards Flashcards

An acupuncturist notices an error in a chart entry written yesterday. What is the correct way to correct a paper record?

Answer: Draw a single line through the error, write the correction, and initial and date it

A single line keeps the original entry readable, and initialing and dating the change keeps the record legally sound.

In a SOAP note, where does the practitioner record tongue and pulse findings?

Answer: Objective

Tongue and pulse findings are observations the practitioner makes, so they go in the Objective section.

Which entry belongs in the Subjective section of an acupuncture SOAP note?

Answer: Patient reports low back pain rated 6/10, worse in the morning

The Subjective section records what the patient reports, including their own pain ratings and symptoms.

Which detail is most important to record about the needles used during a treatment?

Answer: The points needled, the number of needles inserted, and the number removed

Recording the points and matching the counts of needles inserted and removed shows that no needle was left in the patient.

A patient faints during treatment. What should the practitioner document?

Answer: The event, signs observed, actions taken, the patient's response, and the time

Adverse events need a complete, factual, time-stamped record of what happened and how it was managed.

When should a treatment note ideally be completed?

Answer: At the time of service or as soon as possible afterward

Writing notes at or near the time of service gives the most accurate and defensible record.

An entry is added to a chart three days after the visit. How should it be labeled?

Answer: As a late entry, with the current date and a reference to the date of service

A late entry must be clearly marked and dated when it is written, with a reference to the original visit date.