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9 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Source-Oriented Record |
The information is arranged according to the professional who supplied the data |
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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 |
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SOAP is used for what type of record? |
Problem Oriented Medical Record |
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SOAP stands for....? |
Subjective Objective Assessment (Describes what the problem is) Plan (actions taken to address the problem) |
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How should you file store medical records for a patient who has not seen the doctor in a year? |
Label medical records as inactive |
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Records of patients who are deceased or have moved away shoulf be labeled as....? |
Being in a closed file cabinet |
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THE MEDICAL FILE BELONGS TO THE PHYSICIAN OR MEDICAL GROUP, BUT THE INFORMATION IN IT BELONGS TO....? |
THE PATIENT |
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What is a Signed Release of Records is used when....? |
When patients are changing doctors |
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