1. MAR refers to
A. Medical allergies required
B. Medication administration record
C. Medication and allergies record
D. Medical alert record
2. Face sheet refers to
A. The initial patient intake history form
B. Part of a body diagram, such as when there has been a facial laceration
C. Information collected by the admitting or triage nurse
D. Registration form when presenting for hospital care
3. Which of the following does not belong with the others?
A. Progress notes
B. Visit summary
C. SOAP note
D. Interdisciplinary progress notes
Answer: B. Visit summary. A visit summary is documentation given to the patient after an office visit or ER visit. It typically does not include the entire findings of a visit. All of the others likely included subjective complaints, objective (exam) findings, assessment or diagnosis and plan (recommendations).
4. In which of these records would you not find physician documentation?
B. Face Sheet
Answer: A, B, and D. Triage is generally done by a nurse. Face sheet is created by the registration person at the ER or hospital. MAR or medication administration record is created by a pharmacy and contains nurses’ documentation of drugs given. Physicians would complete the ROS or review of systems and the HPI, the history of present illness portions of the history and physical record.