Which section of the Cheddar format is documentation?
MOA Chapter 11
| Term | Definition |
|---|---|
| documentation | process of recording information in the medical record |
| assessment | section of the CHEDDAR format of documentation where the diagnosis can be found |
| the C section | section of the CHEDDAR format of documentation where the presenting problem can be found |
What do the two Ds in Cheddar stand for?
Drug and dosages
Which of the following is included in the SOAP approach to documentation?
The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan.
What is a POMR?
The problem oriented medical record (POMR) has proved to be very successful in providing a structure that helps doctors record their notes about patients, and view those notes subsequently in a manner that quickly gives them a good understanding of that patients history.
What are the four main components of the problem-oriented medical record?
a form of patient-care record that has four components: (a) a database of standardized information on a patient’s history, physical examination, mental status, and so forth; (b) a list of the patient’s problems, drawn from the database; (c) a treatment plan for each problem; and (d) progress notes as related to the …
What best describes the soap soaper format?
a problem-oriented medical record. The SOAP/SOAPER format is: The best method to use for making a correction in paper medical records is: draw a single line through the error, make the correction, write “CORR” or “CORRECTION” above the area corrected, and add your initials and date.
What are the preferred steps for filing medical documentation?
The preferred order for steps in filing medical documentation is: Inspect, index, code, sort, file.
What describes the I in the soaper charting acronym?
Approach to charting that encourages greater detail than SOAP/SOAPER. Stands for Chief Complaint, History, Examination, Details of Problems and Complaints, Drugs and Dosages, Assessment, and Return Visit. You just studied 9 terms!
When filing alphabetically which is the most common method of filing?
Alphabetic systems are the most natural and common method of arranging files. However, even the simplest alphabetic system requires establishing, filing standards, including written filing procedures, cross-reference methods, and practices for filing duplicate name changes, etc.
What are the 5 filing methods?
There are 5 methods of filing:
- Filing by Subject/Category.
- Filing in Alphabetical order.
- Filing by Numbers/Numerical order.
- Filing by Places/Geographical order.
- Filing by Dates/Chronological order.
What is alphabetical filing method?
Alphabetical filing is a method in which files and folders are arranged in order of alphabets of the names of person or institution concerned with such file. In cases where the names of more than one person starts with same letter then second letter of name is taken into consideration, then third and so on.
What are the types of alphabet?
Different alphabets are used over the world:
- Latin Alphabet.
- Cyrillic alphabet.
- Arabic alphabet.
- Brahmic alphabets.
- Mixed: Latin and Cyrilic Alphabet.
- Mixed: Latin and Arabic Alphabet.
- Mixed: no alphabet and other alphabet.
- Other alphabet.
What is the most common alphabet?
E
Which letters start the most words?
There are more English words beginning with the letter ‘s’ than with any other letter. (This is mainly because clusters such as ‘sc’, ‘sh’, ‘sp’, and ‘st’ act almost like independent letters.) The letter ‘e’ only comes about halfway down the order, and the letter ‘x’ unsurprisingly comes last.
Which alphabet is used most in English?
The top ten most common letters in the Concise Oxford English Dictionary, and the percentage of words they appear in, are:
- E – 11.1607%
- A – 8.4966%
- R – 7.5809%
- I – 7.5448%
- O – 7.1635%
- T – 6.9509%
- N – 6.6544%
- S – 5.7351%
What letter is used least?
Few people have ever wondered which letter of the alphabet is the most common used and which is used the least. We were surprised to find out that the letter “Z” is used the least in the alphabet with an estimated frequency of use is 0.07%.