Chapter 11 / Mrs. Johnson class Flashcards
To examine and review a group of patient records for completeness and accurancy- particularly as related to their ability to back up the charges sent to health insurance carriers for reunbursement.
Audit
C= Chief complaint; H= history; E = Examination ; D= Details of problems and complaints. D= Drugs and dosage ; A = Assessment ; R = Return visit information or referral, if applicable.
CHEDDAR
Statistical data relating to the population and particular groups within it.
Demographics
The recording of information in a patient’s medical record; includes detailed notes about each contact with patient and about the treatment plan, patient progress, and treatment outcome.
Documentation
The term used to describe a patient who does not follow the medical advice given.
Noncompliant
Pertaining to data that are readily apparent and measurable, such as vital signs, test results, or physical examination findings.
Objective
A compilation of important information about a patients medical history and present condition.
Patient Record/ Chart
A method of recording data about the health status of a patient in a problem solving system. The POMR preserves the data in an easily accessible way that encourage ongoing assessment and revision of the health care plan by all members of the health care team.
Problem Oriented Medical Record (POMR)
A process of gathering information about a patient’s health history regardless of apparent relevance to the chief complaint.
Review of Systems
An objective or external factor, such as blood pressure, rash,or swelling that can be seen or felt by the physician or measured by an instrument.
Signs
An approach to medical records, documentation that documents information in the following order:
S:(Subjective data) O:( Objective data) A:( Assessment) P:( Plan of action).
Subjective, Objective, Assessment, Plan (SOAP)
Pertaining to data that are obtained from conversation with a person or patient.
Subjective
A subjective or internal, condition felt by a patient, such as pain, headache, or nausea or another indication that generally cannot be seen or felt by the doctor or measured by insurments
Symptom
The transforming of spoken notes into accurate written form.
Transcription
Patient information is arranged within the chart or medical record according to who supplied the data.
Source Oriented Medical Record (SOMR)
