PATIENT ASSESSMENT EXAM 2 MCPHS EXAM
QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED LATEST UPDATE
The medical record is a legal document, name 4 parties that are legally allowed to view it.
1- Court – Medical Legal document
2- Communication tool between providers
4- Health care payment determinations (coding and billing)
5- Quality control and research (education)
What does CMS stand for?
Centers for Medicare and Medicaid Services - the nations
largest payer for healthcare services.
Why do you need to confirm accurateness of reported services and validate site, necessity,
appropriateness of services provided?
audits / fraud
Who cannot legally access a medical record?
police and lawyers
The medical record establishes your _______________ as a health care provider
,establishes your credibility as a health care provider*
Identify general principles of documentation include
Brief notes during exam
Record ASAP
Avoid abbreviations
Document observations only and what a patient tells you, not your personal interpretations
Record expected and unexpected findings
Do not carry forward/ copy & paste
Why do you not carry forward/ copy & paste medical info?
-Can impact patient safety
-Can perpetuate erroneous or outdated information
-Can pose significant legal and regulatory challenges
What are the 4 types of notes?
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Each type of NOTE includes some or all of the following elements (4)
1- Chief complaint (CC)
,2- History of present illness (HPI)
3- Review of systems (ROS)
4- Past, family, and/or social history (PFSH)
What is a problem focused note?
a limited examination of the affected body area or organ system. questions are directed at problem.
What is a Comprehensive note?
a general multi-system examination, or complete examination of a single organ system and other
symptomatic or related body area(s) or organ system(s).
When documenting a comprehensive note, which terms are used to describe the level of service for:
History of Presenting Illness (HPI)
Review of Systems (ROS)
Past, Family, and/or Social HX (PFSH)
Type of History
(HPI) Extended
(ROS) Complete
(PFSH)Complete
Type of History Comprehensive
What does SOAP stand for?
Subjective
, Objective
Assessment
Plan
Subjective means?
What the patent tells you, what you can see /hear
When is there an exception to not do a comprehensive SOAP note?
when a patient presents with an emergent need and initiating treatment is a higher priority
When can you do a Focused note?
-Established patients
-Routine or urgent care visits
-Addresses focused concerns (ankle sprain, finger laceration)
What components go in the SUBJECTIVE part of a SOAP note?
Patient ID info (verify)
Source of info (usually patient)
CC (chief concern)
HPI in paragraph (OLDCARTS)
PMH
Social History (SODAHTIMESS)
Family History
ROS (if it makes more sense to put this directly after the HPI, no one will fault you.)
What does OLDCARTS stand for?
QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED LATEST UPDATE
The medical record is a legal document, name 4 parties that are legally allowed to view it.
1- Court – Medical Legal document
2- Communication tool between providers
4- Health care payment determinations (coding and billing)
5- Quality control and research (education)
What does CMS stand for?
Centers for Medicare and Medicaid Services - the nations
largest payer for healthcare services.
Why do you need to confirm accurateness of reported services and validate site, necessity,
appropriateness of services provided?
audits / fraud
Who cannot legally access a medical record?
police and lawyers
The medical record establishes your _______________ as a health care provider
,establishes your credibility as a health care provider*
Identify general principles of documentation include
Brief notes during exam
Record ASAP
Avoid abbreviations
Document observations only and what a patient tells you, not your personal interpretations
Record expected and unexpected findings
Do not carry forward/ copy & paste
Why do you not carry forward/ copy & paste medical info?
-Can impact patient safety
-Can perpetuate erroneous or outdated information
-Can pose significant legal and regulatory challenges
What are the 4 types of notes?
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Each type of NOTE includes some or all of the following elements (4)
1- Chief complaint (CC)
,2- History of present illness (HPI)
3- Review of systems (ROS)
4- Past, family, and/or social history (PFSH)
What is a problem focused note?
a limited examination of the affected body area or organ system. questions are directed at problem.
What is a Comprehensive note?
a general multi-system examination, or complete examination of a single organ system and other
symptomatic or related body area(s) or organ system(s).
When documenting a comprehensive note, which terms are used to describe the level of service for:
History of Presenting Illness (HPI)
Review of Systems (ROS)
Past, Family, and/or Social HX (PFSH)
Type of History
(HPI) Extended
(ROS) Complete
(PFSH)Complete
Type of History Comprehensive
What does SOAP stand for?
Subjective
, Objective
Assessment
Plan
Subjective means?
What the patent tells you, what you can see /hear
When is there an exception to not do a comprehensive SOAP note?
when a patient presents with an emergent need and initiating treatment is a higher priority
When can you do a Focused note?
-Established patients
-Routine or urgent care visits
-Addresses focused concerns (ankle sprain, finger laceration)
What components go in the SUBJECTIVE part of a SOAP note?
Patient ID info (verify)
Source of info (usually patient)
CC (chief concern)
HPI in paragraph (OLDCARTS)
PMH
Social History (SODAHTIMESS)
Family History
ROS (if it makes more sense to put this directly after the HPI, no one will fault you.)
What does OLDCARTS stand for?
