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Heather Savage HIM 260 Test Your Knowledge Chapter 4 Fill in the Blanks 1. The earliest surviving records describing individual patient care came from St. Bartholomew Hospital in the United Kingdom. In what year? 1123 AD 2. What book indicated that medical notes need to contain information relevant to an individual’s psychological well-being? The Doctor, The Patient, and the Illness 3. POMR stands for? Problem Oriented Medical Record 4. What information is included in the POMR? Problem list, history, exam, laboratory findings, plan of care, & daily SOAP note. 5. What are the elements of the clinical medical decision-making process? Data collection, formulation of problems, devising a management plan, reviewing medical problems, & revision plan of care when it is necessary. 6. What are the two parts of a surgical note called? Heading and body 7. What is the correct way to correct an error in the medical record? Draw a single line through the error, note the error, initial, & date the error. 8. SOAP stands for: Subjective; Objective; Assessment; Plan 9. What three elements are the level of service based on? Site of service, documented level or type of service or procedure, and the medical necessity. 10. What is the main purpose of the progress note? Aid to memory, support for continuity of care, provision of witness to an event for legal, financial, & regulatory purposes. 11. Give three examples of the types of services found in a medical record: a. outpatient office visits b. consultations c. medications & prescriptions 12. Name three ways medical records are used in the modern world: a. Supporting level of service billed b. Provide a method for health statistics to be tracked.