Title: Identify the chart components related to electronic and paper records.
Course: Medical Assistant I (14151-I) > Section: Performing Office Functions

Identification should ensure that the following type of information is included:

- Administrative/demographic
- Financial/insurance
- Correspondence
- Referrals
- Past medical records
- Clinical data
- Progress notes
- Diagnostic information
- Lab results
- Medications

Identification also should include describing methods of organizing the patient's medical record. This should be based on problem-oriented medical record (POMR) and source-oriented medical record (SOMR).

Identification should include the Subjective, Objective, Assessment, and Plan (SOAP) and Subjective, Objective, Assessment, Plan, and Evaluation (SOAPE) charting methods.

Process/Skill Questions:

- What documentary evidence does the medical chart include?
- How does a properly assembled chart protect the legal and safety interests of the patient?
- How does a properly assembled chart serve as the basis of patient care?
- What happens if information is omitted from a patient chart?
- What are the advantages and disadvantages of paper records vs. computer-based records?