term1 Definition1term2 Definition2term3 Definition3
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Source-Oriented Record
The information is arranged according to the professional who supplied the data
Problem-Oriented Medical Record (POMR)
Contains a detailed problem list, educational, diagnostic, and treatment plan; as well as the progress notes
Makes it easier for the physician to follow a patient's progress and treatment
SOAP is used for what type of record?
Problem Oriented Medical Record
SOAP stands for....?
Subjective
Objective
Assessment (Describes what the problem is)
Plan (actions taken to address the problem)
How should you file store medical records for a patient who has not seen the doctor in a year?
Label medical records as inactive
Records of patients who are deceased or have moved away shoulf be labeled as....?
Being in a closed file cabinet
THE MEDICAL FILE BELONGS TO THE PHYSICIAN OR MEDICAL GROUP, BUT THE INFORMATION IN IT BELONGS TO....?
THE PATIENT
What is a Signed Release of Records is used when....?
When patients are changing doctors
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