Medical Records and Charting Flashcards
6 cards from real CMT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Records and Charting flashcards as text
The SOAP format for charting stands for:
Answer: Subjective, Objective, Assessment, Plan
SOAP notes organize documentation into Subjective (patient's complaints), Objective (measurable findings), Assessment (diagnosis), and Plan (treatment).
When a charting error is made in a paper medical record, the correct procedure is to:
Answer: Draw a single line through the error, write 'error,' initial, and date
The correct method is to draw a single line through the error so it remains legible, then write 'error,' initial, and date the correction.
Which of the following is an example of objective data in a medical record?
Answer: Blood pressure of 140/90 mmHg
Blood pressure reading is objective data—it is measurable, quantifiable, and obtained through direct observation or testing.
The primary purpose of medical documentation is to:
Answer: Provide a legal record and facilitate continuity of care
Medical documentation primarily serves as a legal record of care provided and ensures continuity of care between healthcare providers.
Late entries in a medical record should:
Answer: Be documented as 'late entry' with the current date/time and the date/time of the event
Late entries are acceptable but must be clearly labeled as 'late entry' with the current date/time and reference the date/time of the original event.
Which documentation practice could lead to a malpractice claim?
Answer: Charting by exception without facility protocol
Charting by exception without an approved facility protocol can lead to malpractice claims because it may appear that assessments were not performed.