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Instructions for Side by Side Printing
  1. Print the notecards
  2. Fold each page in half along the solid vertical line
  3. Cut out the notecards by cutting along each horizontal dotted line
  4. Optional: Glue, tape or staple the ends of each notecard together
  1. Verify Front of pages is selected for Viewing and print the front of the notecards
  2. Select Back of pages for Viewing and print the back of the notecards
    NOTE: Since the back of the pages are printed in reverse order (last page is printed first), keep the pages in the same order as they were after Step 1. Also, be sure to feed the pages in the same direction as you did in Step 1.
  3. Cut out the notecards by cutting along each horizontal and vertical dotted line
To print: Ctrl+PPrint as a list

19 notecards = 5 pages (4 cards per page)

Viewing:

Ch 11

front 1

The specific information required of a population that must be obtained when a new patient makes an appointment with the office is __________________

back 1

demographics

front 2

The best place to interview a patient is __________.

back 2

in a private room

front 3

The P section of SOAP documentation is __________.

back 3

the plan of action

front 4

The _________ summary form generally includes a summary of the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered in the hospital; and the disposition or outcome of the case.

back 4

discharge

front 5

Subjective or internal conditions felt by the patient are __________.

back 5

symptoms

front 6

When you document problems, be careful to distinguish between signs and symptoms. An example of a sign is __________.

back 6

rash

front 7

The primary problem for which a patient comes to see the healthcare provider is known as the_________ complaint.

back 7

chief

front 8

Part of creating timely and accurate records is maintaining a(n) _________ tone in your writing.

back 8

professional

front 9

A physical examination form that is used during an “oral examination” to identify any signs or symptoms the patient may be experiencing or reveal information about an illness or condition is called a review of _________ or ROS.

back 9

system

front 10

The appropriate way to delete information on a medical record is to __________.

back 10

draw a line through the original information so it is still legible

front 11

Everything that is entered into the patient’s health record by the medical assistant must be dated and ____________.

back 11

initialed

front 12

Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) ___________ professional record of a patient’s case.

back 12

accurate

front 13

When you release medical information, always send _________ unless the record will be used in a court case, in which case you should send the original records.

back 13

copies

front 14

Internal audits are done

back 14

by medical staff on random records.

front 15

The O section of SOAP documentation is __________.

back 15

data that comes from examination results and from the physician

front 16

To reduce confusion in medical records, __________________ are being used less often, except for those that are very clear in meaning.

back 16

abbreviation

front 17

The informed _________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

back 17

consent

front 18

In which section of the CHEDDAR format of documentation can the diagnosis be found?

back 18

assessment

front 19

In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests?

back 19

database