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20 Cards in this Set

  • Front
  • Back
Patient's chart:
Medical Record
chronological system used to annotate patient's medical care that the health care provider renders.
medical record

(legal document)
Main reason for the patient seeking care.
chief complaint (CC)
gives info regarding usual childhood diseases (UCD), past illnesses, surgeries, and current health status; may be prepared by pt, HCP, or MA
past medical history (PH/ PMH)
info regarding the pt's parents and siblings; may include health status, age, cause of death, and hereditary diseases
family history (FH)
expanded CC (chief complaint)
present illness (PI)
info on pt;s personal habits; may include exercise, sleep, diet, tobacco and/or alcohol use, drug use, sexual history, sexual preference, and hobbies
social history (SH)
info regarding pt's employment
occupational history (OH)
complete physical exam; gives info regarding each system (ROS); may serve as a baseline against the future
physical examination (PE)
diagnostic and laboratory tests; arranged with most recent at top
test results
reports on evaluations made by other health care providers
consultations
records from other health care providers that have bearing on present treatment
past medical records
all correspondence related to pt care
correspondence
notes written in the chart by the HCP regarding the pt's care, dx, and tx
progress notes
record of all medications and prescriptions given or renewed in the office
medication/ prescription record
record of all immunizations administered in the office
immunization record
what are the 2 forms of record organization?
source-oriented and problem-oriented
observations and data are categorized by their source; filed in reverse chronological order
source-oriented record

(ie: HCP, laboratory, radiography, nurse)
POMR
problem-oriented medical record
data organize according to pt's disease or condition; divided into 4 parts
problem-oriented medical record