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?