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SOAP Notes Exam Questions And Answers
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SOAP Notes Exam Questions And Answers...
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SOAP Notes Exam Questions And AnswersWhy is documentation important? - Answer Because if it isn't written, it didn't happen
document - Answer anything written that gives information or supplies evidence
documentation - Answer the assembling of documnets; the using of documentary
evidence to support the originial work.the classifying and making available of
knowledge as a procedure.
Why do we document? - Answer - To enhance the quality of patient care
+ communication
+ authenticates/provides evidence
+ holds caregiver accountable-studies/outcomes
To protect the rights of the pts and caregiver-its a legal report
to help with reimbursement from 3rd party payers.
What is important to remember when writing in the medical record? - Answer accuracy,
brevity, clarity, punctuation, correcting errors, signing notes, referring to yourself, no
blank or empty lines, no writing orders.
Top Rules for Documentation - Answer 1. Timeliness
2.Objectvity - avoid opinion
3. Legibility
4. Finished- sign every page of everything
5. Thoroughness - leave no blanks
6. Accuracy
7. Spelling accuracy
8. Approved (standard) abbreviations
, 9. Errorless - do not obliterate
10. Meaningfulness - use only the facts
11. Courtesy - do not joust
12. Authenticate - sign only what is yours
13. Write everything that is pertinent - including phone calls and conversations with
caretakers
14. Follow department policies and procedures
15. Use proper forms
16. Follow rules of confidentiality
17. On electronic documentation identify users
Top reasons for third party denials of payment - Answer 1. Inadequate documentation
2. Imprecise documentation
3. Illegible documentation
4. Good documentation in the wrong place
5. Bad documentation
6. Errors in eligiblity such as:
- not medically necessary
- goals - unreasonable or did not relate to functional needs
- goals - not achieved in a reasonable time
- treatment continued too long
7. Omission of identifying information
8. Incorrect form submitted
9. Treatment required pre-approval
10. Treatment exceeded approved limit of visits
11. Authorization for specfic tx., diagnosis, or body part obtained but treatment to other
provided
12. Non-approved provider
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