Medical Records and Charting Flashcards
12 cards from real CMT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 12 Medical Records and Charting flashcards as text
The SOAP format for charting stands for:
Answer: Subjective, Objective, Assessment, Plan
SOAP notes organize documentation into Subjective (patient's complaints), Objective (measurable findings), Assessment (diagnosis), and Plan (treatment).
When a charting error is made in a paper medical record, the correct procedure is to:
Answer: Draw a single line through the error, write 'error,' initial, and date
The correct method is to draw a single line through the error so it remains legible, then write 'error,' initial, and date the correction.
Which of the following is an example of objective data in a medical record?
Answer: Blood pressure of 140/90 mmHg
Blood pressure reading is objective data—it is measurable, quantifiable, and obtained through direct observation or testing.
The primary purpose of medical documentation is to:
Answer: Provide a legal record and facilitate continuity of care
Medical documentation primarily serves as a legal record of care provided and ensures continuity of care between healthcare providers.
Late entries in a medical record should:
Answer: Be documented as 'late entry' with the current date/time and the date/time of the event
Late entries are acceptable but must be clearly labeled as 'late entry' with the current date/time and reference the date/time of the original event.
Which documentation practice could lead to a malpractice claim?
Answer: Charting by exception without facility protocol
Charting by exception without an approved facility protocol can lead to malpractice claims because it may appear that assessments were not performed.
The SBAR communication format is used primarily for:
Answer: Handoff and critical communication between healthcare providers
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication framework for healthcare handoffs and urgent communications.
Which of the following is an approved abbreviation for 'every day' in medical documentation?
Answer: Daily
The word 'daily' is the approved term. 'QD' and 'q.d.' are on The Joint Commission's Do Not Use list due to confusion with 'QID' and 'QOD.'
When documenting a patient's refusal of treatment, the medical record should include:
Answer: The treatment refused, explanation of risks provided, and patient's stated reason
Documentation of refusal must include what was refused, that risks were explained, the patient's stated reason, and that the provider was notified.
Protected health information (PHI) in electronic records must be safeguarded by:
Answer: Using automatic logoff, encryption, and unique user IDs
HIPAA's Security Rule requires technical safeguards including automatic logoff, encryption, access controls, and unique user identification.
Incident reports in healthcare are used to:
Answer: Document unusual occurrences for risk management and quality improvement
Incident reports document unusual occurrences, near-misses, and adverse events for risk management analysis and quality improvement.
The minimum data set that should be documented for every patient encounter includes:
Answer: Patient identification, date/time, vital signs, assessment, interventions, and provider signature
Every patient encounter requires documentation of identification, date/time, clinical findings, care provided, and provider identification.