Healthcare Documentation Standards and Report Formats
The Healthcare Documentation Standards and Report Formats domain tests whether you know the architecture of common medical reports and the conventions that make a record complete, authenticated, and usable. Items ask you to identify the correct section, heading, or correction method.
Core rules
- History and physical: chief complaint, history of present illness (often OLDCARTS: onset, location, duration, character, aggravating/associated factors, relieving factors, timing, severity), review of systems, past medical/surgical history, medications, allergies, family and social history, physical examination, assessment, and plan.
- SOAP notes organize subjective data, objective data, assessment, and plan. Subjective includes symptoms and history; objective includes examination findings, vitals, and labs.
- Operative report components: preoperative and postoperative diagnosis, procedure, surgeon and assistants, anesthesia, findings, technique, estimated blood loss, complications, specimens, and disposition.
- Discharge summary: admission and discharge diagnoses, hospital course, procedures, discharge medications, activity and diet instructions, follow-up, and condition at discharge.
- Authentication: the author signs and dates entries. Corrections are made with a single line through the error, initials, date, and reason when required; never obliterate or use correction fluid. Addenda and late entries are labeled and timed.
- Formatting: consistent headings, approved abbreviations, complete sentences or accepted note style, and no unexplained blanks.
Worked example
A progress note reads: “S: patient reports 7/10 chest pain. O: BP 150/90, HR 96, lungs clear. A: chest pain, rule out ACS. P: ECG, troponin, aspirin.” The note is structurally sound because symptoms are under S, vitals and exam under O, the clinical impression under A, and orders under P. If the ECG result is added later, it belongs in an addendum with the date and time, not squeezed into the original objective section without attribution. The reasoning is that the record must show what was known and when, and who documented it.
Traps
Do not place laboratory values or examination findings in the subjective section. Do not use unapproved abbreviations or leave a signature block incomplete. Avoid writing a diagnosis in the assessment that is unsupported by the documented findings. Never alter a prior entry without an audit trail; an addendum is not the same as a correction. Do not omit the time of a late entry or the reason for an addendum.