Miscellaneous Vocabulary

Question 1

Source Oriented Record (SOR)

Answer 1

Maintains reports according to source documentation (i.e. Nursing notes, radiology, lab reports are all group together according to department)

Question 2

Problem Oriented Record (POR or POMR)

Answer 2

More systematic method of documentation, which consists of four components: Database, Problem List, Initial Plan & Progress Notes

Question 3

Integrated Record

Answer 3

Usually arranges reports in strict chronological date order

Question 4

SOAP Structure: S - Subjective

Answer 4

Patient’s statement about how she feels, including symptomatic information

Question 5

O - Objective

Answer 5

Observations about the patient, such as physical findings or lab or x-ray results (i.e. Chest x-ray negative)

Question 6

A - Assessment

Answer 6

Judgement, opinion, or evaluation made by the health care provider (i.e. acute migraine)

Question 7

P - Plan

Answer 7

Diagnostic, Therapeutic, and educational plans to resolve the problems (i.e. patient to take Tylenol as needed for pain)