Basic Medical Documentation- CCMA Exam Stepful

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11 Terms

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source oriented medical records

creating and preparing medical records

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subjective (SOAP)

chief complaint

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Objective (SOAP)

measurable data, vital signs, lab results, and measurements

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Assessment (SOAP)

medical diagnosis

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Plan (SOAP)

for treatment

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open-ended questions

questions that lead to further explanation vs and yes or no

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restating

repeating or rephrasing information

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reflection

when the patient

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clarification

summarizing the information relayed to clear up confusion

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closed ended questions

questions that have a limited number of possible responses yes or no

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health insurance portability and accountability

A law implemented in 1996 to improve the portability and continuity of health insurance coverage, contain costs, fraud, and abuse in the healthcare industry; set a higher standard for electronic health information communications, and promote the privacy of health information.