FAMILY HEALTH CARE, FOMR, POMR Flashcards
__________ account of patient’s signs and symptoms, assessment and diagnostics, and treatment received
used for medico-legal purpioses
basis for third party payers
effect teaching and research tool s
medical record
A method of recording data about the health status of the patient
in a problem-solving system
An easily accessible way that encourages ongoing assessment and revision of the healthcare plan by every actor of the healthcare
team
Designed specifically to document and facilitate comprehensive,
continuing care
Introduced by Dr. Lawrence Weed in the late 1950s
problem oriented medical record
_____________ should be defined at its highest level of defensibility
problem list
for each problem defined a ______ note must be recorded
SOAP
3 DISTINCT GROUPINGS OF PLAN
Includes all the diagnostic work up which the admitting physician feels will be necessary
If the Assessment includes the differential diagnosis, then each must be ruled in or ruled out in the diagnostic plan
Must include additional work-up needed either to further define the problem or assess the severity
of the problem
diagnostic plan
3 DISTINCT GROUPINGS OF PLAN
Must detail all initial therapies started and their rationale
therapeutic plan
3 DISTINCT GROUPINGS OF PLAN
details the initiation of plans to educate the patient of what the problem is and how the patient will deal with it in the future
patient education plan
a medical charting system which incorporates features of the problem oriented medical record and allows the recording of aspects of the family situation that are of particular importance to the family physician
family oriented medical record
“An act protecting individual personal information in
information and communications systems in the government and the private sector, creating for this purpose a national privacy commission, and for other purposes” has classified health records as sensitive
personal information
RA 10173
