Patient Record + Exam

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Last updated 8:55 PM on 9/22/26
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9 Terms

1
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Problem-Oriented Medical Record (POMR)

Medical record based on the problem or diagnosis

Mainly used in specialty office

Might have like three sections

2
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Source Oriented Medical Record

Around seven or eight sections

Items are filed based on the record

  • Demographics, consults, referrals, ect all the important information is logged here and it’s filed by the source (aka the person who took that information from different places)

  • Really big


3
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Six Physical Exam Methods

  1. Inspection

  2. Palpation

  3. Auscultation

  4. Percussion

  5. Manipulation

  6. Mensuration


4
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Inspection

To look

5
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Palpation

To feel

6
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Auscultation

To listen

7
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Percussion

To tap

8
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Manipulation

To move

9
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Mensuration

To measure