CMA - CH 10 Key Terms

Question 1

allergies

Answer 1

acquired hypersensitivity to a substance (allergen) that does not normally cause a reaction.

Question 2

CHEDDAR

Answer 2

Form of medical documentation that includes:
C - chief complaint
H - history, social and physical, of presenting problems; contributing data.
E - Examination; body systems reviewed
D - details of problems and complaints
D - drugs and dosages; list of current medications, dosages, frequency.
A - Assessment; diagnostic evaluation, further testing, medications
R - Return visit, if applicable.

Question 3

chief complaint (CC)

Answer 3

specific symptom or problem for which the patient is seeing the provider today

Question 4

clinical diagnosis

Answer 4

identification of a disease by history, laboratory studies, and symptoms

Question 5

DARP

Answer 5

a problem-oriented medical record charting method that is based on data, assessment, response, plan

Question 6

narrative charting

Answer 6

chronological account in paragraphs describing client status, procedures, interventions and treatments, and clients response.

Question 7

objective

Answer 7

a patient sign that is visible, palpable, or measurable by an observer.

Question 8

problem-oriented medical record (POMR)

Answer 8

type of patient chart recordkeeping that uses a sheet at a prominent location in the chart to list vital identification data. Patient medical problems are identified by a number that corresponds to the charting; for example, bronchitis is #1, a broken wrist is #2, etc.

Question 9

SOAP/SOAPIE/SOAPER/SOAPIER

Answer 9

Form of medical documentation that includes all or a portion of the following:
S - subjective data; patients complaint in her or her own words
O - Objective, observable, measurable findings
A - Assessment, probable diagnosis based on subjective and objective factors
P - Plan for treatment, medications, instructions, return visit information
I - Implementation, or how the actions were carried out
E - Education for the patient
R - Response of patient to education and care given or Revision of plan.

Question 10

source-oriented medical record

Answer 10

a type of patient chart record-keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes.

Question 11

subjective

Answer 11

symptom that is felt by the patient but not observable by others.