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Effective Documentation for a Compliant Audiology Practice

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1.  What are the requirements of appropriate documentation? Name and professional identity of provider of care Date of service Legible documentation All of the above

2.  What is the first step in strong documentation of medical necessity? Results Recommendations Case History Plan

3.  The history of the chief complaint can include information regarding: Right ear, left ear or binaural symptoms Congenital and acquired conditions Onset of symptoms All of the above

4.  Current drug and alcohol use is part of the: Chief complaint Family history Social history Review of symptoms

5.  The recommendations are the same as the: Objective findings Results Plan Assessment

6.  How many body systems are contained in the Review of Systems: 5 12 14 18

7.  The S in SOAP notes stands for: Special Secondary Subjective Standardized

8.  The "O" in SOAP notes stands for: On-time Otolaryngology Objective Outpatient

9.  The "A" in SOAP stands for: Assessment Audiology Administration Audiogram

10.  The "P" in SOAP would include: policy and procedures pharmacological history recommendations and plan phone number of patient