CPMA practice exam A Study Guide
SOAP - Answer✔✔-Subjective, Objective, Assessment, Plan
CHEDDAR - Answer✔✔-Chief complaint, Hx, Exam, Details of problem/complaint, Drugs &
dosages, Assessment, Return visit
Subjective - Answer✔✔-Pt complaint
Objective - Answer✔✔-Provider observation
Assessment - Answer✔✔-Medical Dx
Plan - Answer✔✔-Treatment
You are performing an audit of e/m services for a FP office. In the encounter you read the
physician ordered and reviewed a differential WBC. What elements would you expect to see in
the medical records? - Answer✔✔-Patient ID, assignment of benefits, pt's medical hx,
immunizations, physical examination, lab report, clinical impression & physician orders. When
labs are ordered, there must be a copy of the order and the lab report that the physician has
reviewed.
What is the minimum requirement for the signature of the author of an entry in the medical
records? - Answer✔✔-The first initial, last name and credentials
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