mitc
19
qutf

When completing medical documentation, it is best to leave empty lines or spaces prior to your signature for later thoughts or additions.
False
Correct. Leaving empty lines allows someone else to chart information that would be attributed to you, because it occurs prior to your name.
True
Incorrect. Never leave empty lines prior to your signature.

Opinions and personal thoughts can be freely charted, because the medical record is not ever seen by the patient.
False
Correct. Charting should be concise and factual; charts can be viewed by the patient and used in the courtroom.
True
Incorrect. Charting should be concise and factual; charts can be viewed by the patient and used in the courtroom.

SOAP charting and charting by exception are identical in content but vary in organizational format.
False
Correct. Charting by exception has only abnormal findings, but SOAP notes may contain normal and abnormal findings.
True
Incorrect. Charting by exception has only abnormal findings, but SOAP notes may contain normal and abnormal findings.

In good medical documentation, it is important to chart procedures and treatments prior to doing them so others know what you intend to complete and when.
False
Correct. Chart only after completing procedures or treatments.
True
Incorrect. Chart only after completing procedures or treatments.

An assessment is the documentation of procedures, treatments, and patient instructions.
False
Correct. An assessment is the impression of what is wrong with the patient based on the signs and symptoms.
True
Incorrect. A plan documents the procedures, treatments, and patient instructions.

Narrative charting is organized around a patient's health problem.
False
Correct. Narrative charting provides written notes on all aspects of a patient's health.
True
Incorrect. SOAP notes are organized around a patient's health problem.

