WITH COMPLETE SOLUTIONS GRADED A+
◉ Charting. Answer: method that tracks subjective, objective
assessment and plan for a patient's visit.
◉ Subjective. Answer: patient's statements ( chief complaints)
◉ Objective. Answer: observations made by the medical assistant,
examination findings and vital signs.
◉ Assessment. Answer: doctor's diagnosis
◉ Plan. Answer: health care providers prescribed plan of action
◉ POMR Note Charting. Answer: tracks a patient's problems
throughout medical care. Each problem is assigned a number and
the number is referenced when the patient comes in for care.
◉ Flow Charts. Answer: visual tools that help track certain
information in patient's medical records like an infant's/child's
growth.
,◉ Progress Notes. Answer: daily chart notes made during patient's
visits to document patient progress with certain conditions.
◉ Reporting. Answer: is the oral account of care and recording is the
written account of care and observations •
◉ Assessment #2. Answer: involves collecting information about the
person and observation is using the sense of sight, hearing, touch
and smell to collect information.
◉ Objective Data. Answer: is information that is heard, felt or
smelled.
◉ Subjective data. Answer: are things a person tells you about that
you cannot observe through your senses.
◉ Tort. Answer: is a wrong committed against a person or the
person's property. Torts may be intentional or unintentional.
◉ Liable. Answer: is being held accountable under law
◉ Negligence. Answer: Unintentional wrong and must be proven
, ◉ Malpractice. Answer: is negligence by professional person
(unintentional)
◉ Intentional Torts. Answer: are acts that are meant to be harmful.
◉ Deformation. Answer: is injuring a person's name and reputation
by making false statements to a third person.
◉ Libel. Answer: is making false statements in print, writing or
through pictures.
◉ Slander. Answer: is making false statements orally • Invasion of
privacy is violating a person's right not to have his or her private
affairs exposed.
◉ Invasion. Answer: of privacy is violating a person's right not to
have his or her private affairs exposed.
◉ Fraud. Answer: is saying or doing something to trick, fool or
deceive a person.
◉ Assault. Answer: is intentionally attempting to touch or threaten a
person's body without their consent.