QUESTIONS AND ANSWERS SURE A+
✔✔Subjective - ✔✔Any information that the patient provides including chief complaint,
or comments made during an examination
✔✔Objective - ✔✔Information based on observations made by the physician or medical
assistant (lab results, vital signs)
✔✔Assessment - ✔✔A brief summary of the patients symptoms, and may often include
a diagnosis as well as a list of other possible diagnoses
✔✔Plan - ✔✔Consists of any information regarding the prescribed plan of action for a
patient (prescriptions, instructions, referrals)
✔✔Problem Oriented Medical Record (POMR) - ✔✔Charting that tracks patients
problems during the time they are receiving medical care
✔✔Progress Notes - ✔✔Daily chart notes which are used to record any information that
Irish to the various stages of a patients condition
✔✔Flow Chart - ✔✔A visual aid used to keep track of information over a period of time
✔✔Alphabetic Filing System - ✔✔Information is filed according to the patients last name
✔✔Numeric Filing System - ✔✔Information regarding each patient is stored used a
number, instead of the last name
✔✔A Medical Record Contains... - ✔✔Personal information, financial information,
medical information and social information
, ✔✔Personal/Financial Information - ✔✔Includes insurance data, marital status, next of
kin, and other items collected for personal identification
✔✔Medical Information - ✔✔Includes the chief complaint, family/patient medical history,
results of exams, physical exam form, lab reports, etc.
✔✔Social Information - ✔✔Includes items such as race, ethnicity, hobbies, lifestyle
choices
✔✔Self-Insure - ✔✔A method in which the employer pays directly for the employees
medical bills
✔✔Medicare - ✔✔Federal program for patients that are either over the age of 65,
disabled, or considered end-stage renal disease patients
✔✔Medicaid - ✔✔Federal program, state administered, for individuals/families that have
very low income
✔✔TRICARE - ✔✔A benefit program for members of the armed forces, as well as
retired service personnel and they're families
✔✔CHAMPVA - ✔✔A benefit program for veterans with service-related disabilities
✔✔Workers' Compensation - ✔✔Coverage through employers for partners who suffer
from job-related injuries
✔✔Person Who Owns Insurance Policy - ✔✔Member, subscriber, insured, policyholder
✔✔Dependents - ✔✔Family members who are chores tuner the members insurance
policy
✔✔Premium - ✔✔Monthly payment to the insurance company to receive coverage
(usually deducted from paycheck)
✔✔Allowed Amount - ✔✔The amount charged for service determined by the insurance
company
✔✔Provider - ✔✔Physician, specialist, or any person that provides medical care
✔✔Participating Provider (Preferred) - ✔✔Physicians who agree to accept the allowed
amount from the insurance company as a payment in full
✔✔Copayment - ✔✔A fixed amount a patient may be required to pay at the time of their
appointment