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Chapter 9

Medical Record and Notes

QuestionAnswer
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
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