Get Answer: Medical Charting Basics Question Guide

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This topic involves medical charting basics. A strong answer should include explanation, application, and examples.

Original Question

MEDICAL CHARTING BASICS REVIEW WORKSHEET Common Abbreviations: Fill in the blank with the meaning of each abbreviation. 1. Pt 9. NKA HX 10. Bpm 3. C/O 11. F/U 4. HA 12. BP 5 . L 13. C 6. CC 14. DX 7. SOB 15. WNL Y/O 16. DOB Parts of a SOAP note: Match the part of the note with the matching description. 17. Subjective A. This includes any treatment options, tests ordered, or need for follow up for the patient. 18. Objective B. The physician’s diagnosis or impression of the patients problem. C. This information is received from 19. Assessment conversing with the patient and includes thoughts, feelings, including their chief complaint. 20. Plan D. This is measurable data such as vital signs, test results, or observations during an examination

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