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Carnegie MOPS Pt Rec

MOPS Patient Record Unit Test Review MA (Fall 2014)

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
Created by: ma2b