SOAP - ANSWER Subjective, Objective, Assessment, Plan
CHEDDAR - ANSWER Chief complaint, Hx, Exam, Details of problem/complaint, Drugs &
dosages, Assessment, Return visit
Subjective - ANSWER Pt complaint
Objective - ANSWER Provider observation
Assessment - ANSWER Medical Dx
Plan - ANSWER Treatment
You are performing an audit of e/m services for a FP office. In the encounter you read the
physician ordered and reviewed a differential WBC. What elements would you expect to see
in the medical records? - ANSWER Patient ID, assignment of benefits, pt's medical hx, im-
munizations, physical examination, lab report, clinical impression & physician orders. When
labs are ordered, there must be a copy of the order and the lab report that the physician has
reviewed.
What is the minimum requirement for the signature of the author of an entry in the medical
records? - ANSWER The first initial, last name and credentials
Based on JCAHO accreditation guidance for personal data, what two elements must be evi-
dent in the medical records? - ANSWER Personal biographical data and consent for Treat-
ment or authorization for Treatment form.
1
CHEDDAR - ANSWER Chief complaint, Hx, Exam, Details of problem/complaint, Drugs &
dosages, Assessment, Return visit
Subjective - ANSWER Pt complaint
Objective - ANSWER Provider observation
Assessment - ANSWER Medical Dx
Plan - ANSWER Treatment
You are performing an audit of e/m services for a FP office. In the encounter you read the
physician ordered and reviewed a differential WBC. What elements would you expect to see
in the medical records? - ANSWER Patient ID, assignment of benefits, pt's medical hx, im-
munizations, physical examination, lab report, clinical impression & physician orders. When
labs are ordered, there must be a copy of the order and the lab report that the physician has
reviewed.
What is the minimum requirement for the signature of the author of an entry in the medical
records? - ANSWER The first initial, last name and credentials
Based on JCAHO accreditation guidance for personal data, what two elements must be evi-
dent in the medical records? - ANSWER Personal biographical data and consent for Treat-
ment or authorization for Treatment form.
1
