Medical Terminology - Medical Record

Front 1

POMR

Back 1

Problem Oriented Medical Record

Hint 1

- health record with focus on patient's problem
- information organised for access at a glans
-documents thought process of provider

Consists of 4 Sections:
- Database
- Problem list
- Initial plan
- Progress notes

Front 2

SOAP

Back 2

S = subjective
O = objective
A = assessment
P = plan

Front 3

SOAP Notes

Back 3

progress notes made after the initial history & physical is recorded. the letters represent the order in which progress is noted:
S
O
A
P

Hint 3

S:subjective - which patient describes
O:objective - observable info, e.g: test
results, blood pressure readings etc
A:assessment - progress & evaluation
of effectiveness of the plan
P:plan - decision to proceed or alter
strategy

Front 4

Hospital Records:
1 - history and physical

Back 4

documentation of the patient's recent medical history & results of a physical examination required before hospital admission (e.g. before admission for surgery)

Front 5

Hospital Records:
2 - consent form

Back 5

document signed by the patient or legal guardian giving permission for medical or surgical care

Front 6

Hospital Records:
3 - informed consent

Back 6

consent of a patient after being informed of the risks and benefits of a procedure and alternatives--often req. by law when a reasonable risk is involved (e.g. surgery)

Front 7

Hospital Records:
4 - physician's orders

Back 7

a record of all orders directed by the attending physician

Front 8

Hospital Records:
5 - diagnostic tests / laboratory reports

Back 8

record of results of various tests & procedures used in evaluating and treating of a patient (laboratory tests, x-rays)

Front 9

Hospital Records:
6 - nurse's notes

Back 9

documentation of patient care by the nursing staff

Front 10

Hospital Records:
7 - physician's progress notes

Back 10

physician's daily account of patient's response to treatment, including results of tests, assessment & future treatment plans

Front 11

Hospital Records:
8 - ancillary reports

Back 11

miscellaneous records of procedures/therapies provided during a patient's care (e.g. physical therapy, respiratory therapy)

Front 12

Hospital Records:
9 - consultation report

Back 12

report filed by a specialist asked by the attending physician to evaluate a difficult case

Front 13

Hospital Records:
10 - operative report
(what's its abbreviation?)

Back 13

(op report)
surgeon's detailed account of the operation incl. the method of incision, technique, instrument used, types of sutures, method of closure & patient's responses during the procedure & at the time of transfer to recovery

Front 14

Hospital Records:
11 - pathology report

Back 14

report of the findings of a pathologist after the study of tissue (e.g. biopsy)

Front 15

Hospital Records:
12 - anesthesiologist's report

Back 15

anesthesiologist's/anesthetist's report of the details of anesthesia during surgery, incl. the drugs used, dose & time given, & records indicating monitoring of the patient's vital status throughout the procedure

Front 16

Hospital Records:
13 -
discharge summary,
clinical resume,
clinical summary,
discharge abstract

Back 16

4 terms that describe an outline summary of the patient's hospital care, incl. date of admission, diagnosis, course of treatment, final diagnosis & date of discharge