A heading of ASSESSMENT is part of a SOAP note.

The PAST MEDICAL HISTORY section records the patient’s past complaints, problems, and diagnoses.

According to the Joint Commission, the timeframe for completing a History and Physical report for admission is 48 hours.

Document formatting should begin flush with the left margin.

Drug allergies recorded in the ALLERGIES AND INTOLERANCES section should be bold and all capital letters.

A Referral Note must include the vital signs.

Procedure Notes and Operative Notes are the same.

History and Physical reports must be completed within twenty-four hours of hospital admission.

The established regulation on a TAT for a Consultation Note is twelve hours.

There are reference standards for the order of headings in an Operative Note.

A VITAL SIGNS section may include the patient’s height and weight.

A serif font is preferred for medical documentation for readability reasons.

Subheadings should be in all capital letters.

A DISCHARGE DIAGNOSIS section will include the problems and diagnoses that occurred during the hospitalization.

A PREOPERATIVE DIAGNOSIS section includes the surgeon’s opinion on a diagnosis that will be confirmed by a procedure.

History and physical exams should be performed within twenty-four hours of inpatient admission.

Use a double space after a period between sentences.

The CHIEF COMPLAINT section includes the clinician’s conclusion.

The patient’s marital status is included in a GENERAL STATUS section.

All text should be typed flush to the left margin.

Verbatim transcription means it is error-free.

You should refer derogatory remarks to risk management.

You may edit a medical record to correct translation errors made by speech recognition.

Flagging a document that needs to be reviewed by risk management is acceptable.

You should not edit syntax to maintain the dictator’s style.

You must edit a run-on sentence.

You should always correct dictated punctuation errors that do not affect meaning or readability.

When a portion of dictation is missing, you should leave a blank and flag.

You should edit pronouns in the record to align with the patient’s gender.

Derogatory remarks about a patient’s family member should be left as dictated and flagged to Risk Management for review.

When asking a question within a direct quote, the question mark should be inside the end quotation marks.

Abbreviations in treatment and drug dosing instructions should include a period.

A comma should be used to separate groups of three numerals in five digits or more but omitted if the number includes a decimal

A comma should be used to separate two or more adjectives modifying the same noun.

Abbreviated units of measure should include a period.

Do not use a comma to separate a person’s name from a credential.

A comma should not be used to separate the day of the month from the year.

Do not use a comma to separate the state and zip code.

Commas are not used to separate values of a single panel or test.

Use a colon followed by one space to separate the heading from a content set on the same line.

A hyphen should not be used with a prefix that precedes a proper noun.

A virgule may be used when expressing duality, taking the place of “or” or “and.”

You can use a virgule where two terms are of equal weight in the expression.

Use a hyphen with all disease-entity modifiers that precede a noun.

Hyphens should be used to create compound modifiers formed with one-word modifiers and prefixes.

A virgule should be used when expressing visual acuity with Arabic numerals.

When using an exclamation point as part of a direct quote, the exclamation point should be outside the quotation marks.

Lower-case letters should be used to begin quotations if they represent an independent clause.

Double quotation marks should be used to represent feet and inches in dimensional expression.

Punctuation marks should be inside the closing quotation marks in direct quotes.