mitc
19
qufi

The type of charting that is organized around a patient's health problems is called _____ charting.
problem-oriented
problem oriented

The type of charting that consists of written notes on all aspects of a patient's health problem(s) is called _____ charting.
narrative

The type of charting that is an abbreviated format based only on a patient's abnormal findings is called _____.
charting by exception

The health care professional's impression of what is wrong with a patient based on his or her signs and symptoms is called a/an _____.
assessment

Documents on the procedures, treatments, and patient instructions that make up the patient care are called the _____.
plan

The reason the patient states why he or she is seeking medical care is called the _____.
chief complaint

Written chronological statements about a patient's care are called _____.
progress notes

One example of what may be found in a medical record is _____.
patient medical history
physician's order
medication prescribed
diagnosis
diagnostic test result
diagnostic finding
admission form
admissions form
consent
consent form
surgical procedure consent
surgical procedure report
vital signs
blood pressure
temperature
pulse
respiratory rate
flow sheet
medication record

Good medical documentation must be complete, concise, factual, and _____; must properly identify the patient's name and identifying numbers; must use correct spelling, terminology, punctuation, and grammar; and must be clearly and objectively expressed.
legible

