1. Narrative Style Charting - ANS ✓Physicians dictate notes about
patients care, then gave rise notes transcribed and placed in the
patients chart
2. SOAP - ANS ✓Subjective, objective, assessment, plan
3. Subjective - ANS ✓Any information that the patient provides
including chief complaint, or comments made during an examination
4. Objective - ANS ✓Information based on observations made by the
physician or medical assistant (lab results, vital signs)
5. Assessment - ANS ✓A brief summary of the patients symptoms, and
may often include a diagnosis as well as a list of other possible
diagnoses
6. Plan - ANS ✓Consists of any information regarding the prescribed
plan of action for a patient (prescriptions, instructions, referrals)
AMCA Certification
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AMCA
7. Problem Oriented Medical Record (POMR) - ANS ✓Charting that
tracks patients problems during the time they are receiving medical
care
8. Progress Notes - ANS ✓Daily chart notes which are used to record
any information that Irish to the various stages of a patients
condition
9. Flow Chart - ANS ✓A visual aid used to keep track of information
over a period of time
10. Alphabetic Filing System - ANS ✓Information is filed
according to the patients last name
11. Numeric Filing System - ANS ✓Information regarding each
patient is stored used a number, instead of the last name
12. A Medical Record Contains... - ANS ✓Personal information,
financial information, medical information and social information
13. Personal/Financial Information - ANS ✓Includes insurance
data, marital status, next of kin, and other items collected for
personal identification
14. Medical Information - ANS ✓Includes the chief complaint,
family/patient medical history, results of exams, physical exam form,
lab reports, etc.
15. Social Information - ANS ✓Includes items such as race,
ethnicity, hobbies, lifestyle choices
AMCA Certification
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AMCA
16. Self-Insure - ANS ✓A method in which the employer pays
directly for the employees medical bills
17. Medicare - ANS ✓Federal program for patients that are either
over the age of 65, disabled, or considered end-stage renal disease
patients
18. Medicaid - ANS ✓Federal program, state administered, for
individuals/families that have very low income
19. TRICARE - ANS ✓A benefit program for members of the armed
forces, as well as retired service personnel and they're families
20. CHAMPVA - ANS ✓A benefit program for veterans with
service-related disabilities
21. Workers' Compensation - ANS ✓Coverage through
employers for partners who suffer from job-related injuries
22. Person Who Owns Insurance Policy - ANS ✓Member,
subscriber, insured, policyholder
23. Dependents - ANS ✓Family members who are chores tuner
the members insurance policy
24. Premium - ANS ✓Monthly payment to the insurance company
to receive coverage (usually deducted from pay check)
AMCA Certification
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