CMT Medical Records and Charting 2

Question 1

The SOAP format for charting stands for:

Accepted Answer

Subjective, Objective, Assessment, Plan

Answer

Signs, Objectives, Assessment, Procedure

Answer

Summary, Observation, Action, Prognosis

Answer

Symptoms, Outcomes, Analysis, Protocol

Question 2

When a charting error is made in a paper medical record, the correct procedure is to:

Accepted Answer

Draw a single line through the error, write 'error,' initial, and date

Answer

Use correction fluid to cover the error

Answer

Completely black out the error with marker

Answer

Remove the page and rewrite it

Question 3

Which of the following is an example of objective data in a medical record?

Accepted Answer

Blood pressure of 140/90 mmHg

Answer

Patient states 'I feel dizzy'

Answer

Patient reports pain level of 8/10

Answer

Family member says patient has not been eating

Question 4

The primary purpose of medical documentation is to:

Accepted Answer

Provide a legal record and facilitate continuity of care

Answer

Satisfy administrative requirements

Answer

Generate billing codes

Answer

Track employee productivity

Question 5

Late entries in a medical record should:

Accepted Answer

Be documented as 'late entry' with the current date/time and the date/time of the event

Answer

Never be made under any circumstances

Answer

Be backdated to appear as if they were written at the correct time

Answer

Be written on a separate piece of paper and attached

Question 6

Which documentation practice could lead to a malpractice claim?

Accepted Answer

Charting by exception without facility protocol

Answer

Documenting vital signs immediately after taking them

Answer

Using only approved abbreviations

Answer

Including the date and time on all entries