medical records

documentation

recording information in the medical record (if it isn’t documented, it didnt happen)

maintenance

verifying accuracy

releasing

with proper signatures and verification

medical records

• support pt claim of malpractice

• support doctor in defense against claim

  • back up information within the financial record

noncomplient patient

pt who does not follow medical advice they receive

review of systems

identify signs or symptoms pt may be experiencing that may reveal info abt illness or condition

SOAP

arranges the progress note according to subjective, objective, assessment, plan

subjective

chief complaint, info pt tells MA

objective

measurable data; vital signs, lab results, measurements

assessment

medical diagnosis, impression of pt problem that leads to diagnosis

• of diagnostic process and diagnosis

plan

for treatment

CHEDDAR

expands on SOAP

chief complaint

presenting problems, subjective statements

history

social and physical history

examination

including extent of body systems explained

details

documented

drugs and dosage

drugs and dosage

return visit

info or referral

six C’s

client’s words, clarity, completeness, conciseness, chronological order, confidentiality