Fichas
Chapter 3: The Complete Medical Record and Electronic Charting
Fichas del conjunto (4)
- 1Source- Oriented Medical Record (SOMR)more traditional format used for recording data
-divided into specific sections: history and physical, progress notes, nursing/medical assisting notes, laboratory, and diagnostic testing
*progress notes are usually recorded in a narrative format
*all reports and notes are kept in reverse chronological order - 2Problem-Oriented Medical Record (POMR)-created in 1970s by Lawrence L. Weed; POR
-Database: patient history, physical findings, and baseline readings for testing
-Detailed problem list: records specific problems , should list any new problems
-A plan of action for each problem. - 3Subjective, Objective, Assessment, Plan (SOAP)the POMR system uses the SOAP system
-Subjective: info provided by patient
-Objective: info provider by professional
-Assessment: interpretation of findings
_Plan: the providers plan - 4Contents of the Medical Record- physician's personal preference
-type of practice
-cost of supplies
-regulatory requirements