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Medical Record Documentation Quiz

medical files

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

4. In which of these records would you not find physician documentation?

A. Triage
B. Face Sheet
C. ROS
D. MAR
E. HPI

  • Click here for QUIZ ANSWERS >>

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