Medical Office Assistant · Administrative Procedures and Office Management

Problem-Oriented Medical Record and SOAP Notes

On this page 3 sections
  1. Quick check
  2. Study tools
  3. Sources & references

Quick check

5 questions here, of 85 in this lesson’s practice set. Answers stay hidden until you check.

Question 1 of 5foundational

In the term POMR, the letter P stands for which word?

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Question 2 of 5foundational

Which of the following correctly lists what the letters in SOAP stand for?

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Question 3 of 5foundational

In a problem-oriented medical record (POMR), what is the central organizing tool?

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Question 4 of 5foundational

A problem-oriented medical record is organized around which of the following?

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Question 5 of 5foundational

Which type of information belongs in the Subjective (S) section of a SOAP note?

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Study tools & related lessonsYou’ll learn to · Related

You’ll learn to

  • Describe the problem-oriented medical record (POMR) and the role of the problem list.
  • Explain the structure and purpose of the SOAP note and correctly classify information into its four sections.
  • Identify who documents each part of the record and the medical office assistant's supportive documentation role.
  • Apply HIPAA privacy, access, amendment, and minimum necessary principles to medical record documentation.
  • Recognize documentation integrity and safety practices, including proper corrections, timeliness, and escalation of errors.

Sources & references

  1. U.S. Department of Health and Human Services — Health Information Privacy (HIPAA)
  2. U.S. Department of Health and Human Services — Summary of the HIPAA Privacy Rule
  3. Office of the National Coordinator for Health IT — Privacy, Security, and HIPAA

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