Chapter 3: The Complete Medical Record and Electronic Charting

Question	Answer
Source- 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
Problem-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.
Subjective, 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
Contents of the Medical Record	- physician's personal preference -type of practice -cost of supplies -regulatory requirements

Resource summary

	Created by La'Shae almost 9 years ago