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Carnegie MOPS Pt Rec
MOPS Patient Record Unit Test Review MA (Fall 2014)
Question | Answer |
---|---|
What is the difference between a medical report and medical record? | A report is a single document. A record is a complete set of information. |
The determination of a disease is known as the | diagnosis |
The study of the causes of a disease is known as | etiology |
The forecasted outcome of a disease is | prognosis |
A sign is_________ information | objective |
A symptom is _______ information | subjective |
SOAP is an acronym for | subjective objective assessment plan |
What is the proper procedure for correcting an error in a patient's chart? | Draw a line through error, inital and date it |
List three benefits of shingling | Saves space within the chart. prevents loss of reports, ease for finding information |
The SOAP approach of writing progress notes is known as the _________ method of record keeping | traditional |
Whether you shingle or not, how should reports be placed in a patient's chart? | reverse chronological order |
List three things medical records are used for: | patient education, research, evaluating quality of treatment |
Know that the patient record is a legal document and always kept confidential | |
Congenital means | from birth |
Give one example of a congenital defect | Club feet, Down's Syndrome, born without limbs |
Should the physician always chart the condition of a patient upon termination of treatment? Is this information subjective or objective | Yes, objective |
What should be done before any transcribed notes or laboratory reports are placed in a patient's medical record? | Should be reviewed and intialed by physician |
What does the acronym POMR stand for? | Problem oriented medical record |
What is percusssion | To tap on the body |
What is inspection | To observe |
What is palpation? | To feel |
What is auscultation | To listen |
How does the correction of a hadnwritten entry differ from that of a typewritten entry? | No difference |