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Ch 22 NTQÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â The Patient History and Documentation
clinical medical assisting
1.     What is the difference in age between an infant and a child?
2.     According to your text, what is the age range for adolescents?
3.     According to Erikson, what is the major concern of an adult age 18-40 year of age?
4.     List the items included in a medical health history?
5.     What do the letter in the charting method SOAPIER and CHEDDER represent?
6.     What is the primary purpose and other purposes of the patient record?
7.     To whom does the patient record belong?
8.     How many anatomic locations are examined during a review of systems by the provider?
9.     Explain the security measures that should be in place when storing and retrieving patient’s paper and electronic medical record, and when faxing patient information.
10. List the components of a patient’s medical record.
11. What is a CCR and what information is contained in a CCR and expanded CCR.
12. When is a CCR written and who completes the CCR?
13. What is the difference between SOMR and POMR?
14. What are the four major components of a POMR?
15. Explain DARP charting.
16. Is the use of EMR optional or not? Explain.
17. List some advantages of using EMR.
18. Select at least 5 charting rules that stand out to you from Table 22-2 and 22-3.
19. When are medications errors more likely to occur?
SCIENCE
HEALTH SCIENCE
NURSING
