RECORDS MANAGEMENT Flashcards
POMR
problem-oriented medical record
(the history and physical exam database; a detailed patient problem list; an educational, diagnostic, and treatment plan; as well as the progress notes)
SOAP approach
Subjective: this information comes from the patient describing their signs and symptoms; it is recommended that you use direct quotes or paraphrase the patient’s subjective comments about their status
Objective: this information comes from the health care provider’s observations and measurements including vital signs, examination results, and laboratory test results
Assessment: this information describes the diagnosis of the patient’s problem or what the provider believes is the condition facing the patient
Plan: this component of the documentation states action or steps that will be taken to address the patient’s problem; this includes recommended medications, treatment, consultations, patient’s education, and follow-up care. The plan should always be discussed with the patient prior the end of the office visit. In some cases, written instructions should be provided
full block format
all content is aligned on the left side of the document
modified block format
the date and the closing compliment are centered on the page. All other content is aligned on the left side of the document
semi-block format
the date and the closing compliment are centered on the page. The start of each new paragraph in the body is indented five spaces to the right, but all other content not already specified is aligned on the left side of the document
hanging indentation format
the date and the closing compliment are centered on the page. The first line of every paragraph in the body and other content not already specified is aligned on the left side of the document. The subsequent lines of every paragraph in the body are indented five spaces to the right.
simplified format
all content is aligned on the left side of the document. However, this format does not include a greeting or a closing compliment.
letter
- heading
- opening
- body
- closing
memoranda (memo)
- to
- from
- date
- subject
manuscripts
- title page
- acknowledgements
- summary
- text
- references
- footnotes
- bibliography
- graphic elements
EHRs
electronic health records