Chapter 13 Worksheet: The Medical Record, Documentation, and Filing
Name: __Camarillo, Christopher___
AM or PM
Date: __09/28/2016__
Words to Know Challenge
Spelling: Each line contains three spellings of a word. Underline the correctly
spelled word.
1. awdit audet audit
2. ubjective objective objetive
3. progress notes progriss notes progras notes
4. subjective sobjective subjetave
5. docyumentation documintation documentation
6. ethnicity ethincity ethnicaty
7. privacy prevasy prevacy
8. chronalogic chronologic kronologic
Fill in the Blank: Complete the following sentences with Words to Know from
this chapter.
1. EHR is an acronym for: ____electronic health record___________
2. Per HIPAA, each office is required to have a designated _privacy_ _officer_. This
person must keep track of who has access to protected health information within a
facility.
3. Progress notes are entered in the chart in _________________________ order.
4. Three types of charting styles discussed in this chapter include ___________,
__________, and________________.
5. In the early 1970s, Lawrence L. Weed, M.D., originated a system of recordkeeping for
patients called the_______________________________________________. Progress notes are
organized and entered based on the source from which they come whether from a
provider, laboratory, or other source.
6. The _____________________is the presenting problem and should be recorded in the
medical record in the patients own words.
7. A ________________can be an expanding file, a card file, or even a portion of a file
drawer. It consists of dividers with the names of all the months and dividers numbered
from 1 to 31 for the days of the month.
8. ____________ means to clean out.
Chapter Review
Short Answer
1. What is meant by meaningful use of EHRs?
2. What types of nonmedical information is kept as part of the medical record?
3. Why is it important to obtain records about new patients from other providers?
4. What is an OUT guide used for in filing?
5. Describe the necessary steps for pulling a file.
6. Name the steps for filing a record.
7. What is a tickler file?
8. What is meant by indexing files?
9. Fill in the blanks in the following chart, telling what each initial of SOAP represents and
what the meaning is.
Initial
Represents
Meaning
Subjective
Objective
Assessment
Activity That Takes Place in This Phase
Patient account of symptoms, sensatio
timing, or associated events
Physical exam, vital signs, laboratory t
, radiologic examinations, other
diagnostics
Assimilates subjective and objective
Matching: Tell what each initial of CHEDDAR represents and then match each
initial (letter) with its
description.
Initial: Initial Represents: Description:
_e__1. C __Chief Complaint____
A. Medications and amounts
_f__2. H __History__________
B. Follow-up
_g__3. E __Examination______
C. Test results, additional findings
_c__4. D __Details of Problems _
D. Diagnosis and plan
_a__5. D__Drugs/Dosages_______
E. Presenting problem
_d__6. A __Assessment______
F. Past medical events and problems
_b__7. R __Return Visit________
G. Objective findings
Matching: For each of the following statements, identify whether the
statement is subjective or objective.
__subjective_________ 1. I have a burning pain in my chest.
__subjective_________ 2. My daughter has a fever.
__objective
__objective
__objective
__objective
_________
_________
_________
_________
3.
4.
5.
6.
The baby is lethargic and has no tears when she cries.
She looks queasy.
His skin is pale and diaphoretic.
The childs temperature is 38.1C/100.5F orally.
Chapter Application
Competency Practice
1. In the course of recording patient information in the chart, it is noticed that an error
was made.
a. Describe the correct procedure for making the correction..
b. On the following progress note entry, use the preceding procedure you described and
correct the entry:
Ms. Jones called with complaints of right-upper quadrant abdominal pain.
3/2/201
0
4:15
p.m.
Ms. Jones called regarding complaints of left upper quadrant
abdominal pain that gets worse with eating. She has been
using TUMS for relief and feels better when sitting up. Will
make appointment with Dr. Anderson for tomorrow. Kelly
Taylor, MA
2. Filing Steps. Place the following steps in correct order to file a chart from 1 to 5.
4
3
1
5
2
SORTING
CODING
INSPECTING
STORING
INDEXING
3. Alphabetic Filing. Place the following patient names in order from 1 to 9.
Order
6
9
8
5
3
4
1
7
2
Name
Mary Brown
Katherine Browning
Jessie Browning, Sr.
Kelly Brooks
Amy Barnes
Kendra Barrett
Xena Baers
James Browne
Adele Barne
