Medical Records and Documentation

noncompliant

patient who does not follow the medical advice given

patient record/chart

a compliation of important information about a ptient’s medical history and present condition

demographic

statistical data relating to the population and particular groups within it

symptom

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 measured by instruments

problem oriented medical record (POMR)

a format of medical records documentation developed by Lawrence L Weed MD which makes it easier for the physician to keep track of a patient’s progress

audit

to examine and review a group of patient records for accuracy

documentation

the recording of information in a patient’s medical record

sign

an external factor like blood presssure, rash, or swelling that can be felt by the physician or measured by an instrument

transcription

the transforming of spoken notes into accurate written form

SOAP

What the patient says (subject), what the doctor observes (object), doctor’s diagnosis (assessment), next steps/treatment (plan). A four component format of medical records documentation

subjective

pertaining to data that is obtained from conversation with a person or patient

objective

pertaining to data that are readily apparent and measurable, such as vital signs, test results, or physical exmination findings

CHEDDAR

Chief complaint, History, Examination, Details of problem, Drugs/Dosages, Assessment, Return visit. a format of medical records documentation

Source Oriented Medical Record (SOAR)

a format of medical records documentation; organized according to who supplied the data (i.e., patient, treating physician, speacialist, hospital, lab, etc)

Review of Symptoms

A processs of gathering information about a patient’s health history regardless of apparent revelance to the cheif complaint