Across
- 5. _____ consent forms advise the patient on treatment options, risks of procedures, and voluntary participation.
- 8. If a patient brings in _____ results from another physician, the MA should not throw them out because you will do your own tests, but keep them with the chart and document the information.
- 9. To correct any entry in a medical record, draw a _____ line through the error, initial and date, then make the correction.
- 12. History of heart murmurs, Problems with asthma, and _____ are included on a medical history form?
- 13. Original _______ legally belongs to the physician and belongs in the patient’s medical chart
- 15. The actual medical record belongs to the ____
- 16. Which of the elements of SOAP charting describes the data that comes directly from the patient
- 18. _______ calls require documentation in the patient chart.
- 19. ______ in charting means not leaving out information
- 22. Transforming spoken notes into accurate form.
Down
- 1. Of the six Cs ______ means “getting to the point”
- 2. As a general rule, if information is not______, no one can prove that an event or a procedure took place
- 3. ______ from other physicians cannot be released by a medical office?
- 4. A patient's history of present illness includes ______ and onset of disease
- 6. Patient’s _________ words should be included when documenting in a patient’s medical record?
- 7. If a child lives with his mother who is divorced from his father, the mother or father may sign the _____ of information.
- 10. Which of the elements of SOAP charting describes the course of treatment to be followed?
- 11. Patient _____ form is the first form used in initiating a patient financial record.
- 14. BP 160/92 would be filed under _______ using the SOAP documentation method
- 17. Records of people age _____ and older are held in confidentiality
- 19. Client’s words, clarity, completeness, conciseness, chronological order, and confidentiality are the six Cs of ____.
- 20. Abbreviation for physical therapy
- 21. The P in SOAP documentation stands for