Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Chapter 9
Medical Record and Notes
| Question | Answer |
|---|---|
| Typed or handwritten information that documents facts and events during administration of pt care | Patients medical record |
| Describe symptoms, problem | |
| Electric Health Record | EHR |
| Aids in diagnosis and treatment, written document of care, verifies medical necessity, | |
| Subjective, Objective, Assessment, Plan | S.O.A.P. |
| The method of treatment | Plan |
| Procedures and coarse of action | Assessment |
| What's in the mind | Subjective Information |
| What you can see | Objective Information |
| In pts own words, describe symptom, problem, condition | Chief complaint (CC) |
| Detailed account of illness or injury the pt is being seen for | history of present illness(HPI) |
| Documentation Format | SOAP |
| Do not interpet reports/ charts | MA's |
| preformed by gov programs, managed care, private insurance carriers | External Audits |
| System composed of blood, blood-forming structures, and the lymphatics | Hematology/Lymphatic |
| System that is focused on the ability to fight disease | Allergic/Immunologic |
| System that deals with the interaction between the mind and body | Psychiatric |
| Physician findings by examination or test | Physical examination |
| Head, eyes, ears, nose, throat | HEENT |
| Normocephalic atraumatic | NCAT |
| Mucous membranes moist | MMM |
| Extraocular | EOMI |
| Pupils, equal, round and reactive to light and acommidations | PERRLA |
| Risk, Diagnosis, Treatment, Prognosis | Complexity of Medical Decision Making |
| Complications, morbidities, comcrobidites,morality | Risk |
| Impression, assessment, final conculsion | Diagnosis |
| Treatment for diagnosis, recommended plan of care | Treatment |
| Probable outcome, prospect of recovery | Prognosis |
| Physician to review and initial/sign, MA's do not interpret reports, | Progress or Chart Notes |
| Performed by: Govt, Managed care, Private insurance carriers | External Audit |
| Use highlight, underline, or score-through to note the words or section in error, never use correction fluid, do not obscure original entry | Correcting a medical record |
| Past(PH), family(FH), and social history(SH) | Patients Medical History |
| Childhood disease | (PH) |
| Smoking, drinking, coffee habits | Social history |
| Physical make up of body | Constitutional symptoms |
| System that includes the heart and blood vessels | Cardiovascular(CV) |
| Systems that pertain to the covering of the body | Integumentary (skin and Breast) |
Created by:
jcpickens
Popular Business sets