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11 Cards in this Set
- Front
- Back
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allergies |
acquired hypersensitivity to a substance that does not normally cause a reaction |
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CHEDDAR |
a form of medical documentation that includes: C: chief complaint, presenting problems, subjective information H: history, social and physical, of presenting problem; contributing data E: examination; body systems reviewed D: details of problem(s) and complaint(s) D: drugs and dosages; list of current medications, dosages, frequency A: assessment; diagnostic evaluation, further testing, medications R: return visit, if applicable |
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chief complaint (CC) |
specific symptom or problem for which the patient is seeing the provider today |
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clinical diagnosis |
identification of a disease by history, laboratory studies, and symptoms |
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DARP |
a problem-oriented medical record charting method that is based on data, assessment, response, and plan |
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narrative charting |
a chronological account in paragraphs describing silent status, procedures, interventions and treatments, and client’s response |
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objective |
a patient sign that is visible, palpable, or measurable by an observer |
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problem-oriented medical record (POMR) |
a type of patient chart recordkeeping that uses a sheet at a prominent location in the chart to list vital identification data. Patient medical problems are identified by a number that corresponds to the charting; for example, bronchitis is #1, a broken wrist is #2, and so forth |
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SOAP/SOAPIE/SOAPER/SOAPIER |
a form of medical documentation that includes all or a portion of the following: S: subjective data; patient’s complaint in his or her own words O: objective, observable, measurable findings A: assessment, probable diagnosis based on subjective and objective factors P: plan for treatment, medications, instructions, return visit information I: implementation, or how the actions were carried out E: education for the patient R: response of the patient to education and care given or Revision of the plan |
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source-oriented medical record (SOMR) |
a type of patient chart record-keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes |
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subjective |
symptom that is felt by the patient but not observable by others |
