professions test

attending physician

MD responsible for hospital care

chart diagnostic procedures

date, time, type of procedures ordered, scheduling date and place of procedure

chart format POMR

problem oriented medical record, documents are organized according to the patients' health conditions

chart format SOMR

source oriented medical record, documents are organized into sections according to the department/facility that generated them

charting connections

errors are never stricken corrections are made with a single line drawn through the error

charting guidelines

check the name on the chart to ensure you are charting the correct record, entries should be legible in ink, dated and initialed, chart immediately after performing a procedure

charting lab results

date, time, test, test results

charting medication administration

date, time, medication, dosage, route, site

charting patient instructions

date, time, type of instructions communicated to patient

charting procedures

date, time, type of procedure, outcome, patient reaction, initials

charting specimen collections

date, time, type of specimen, site of collection test requested

chief complaint

the reason the patient is seeking care, recorded concisely in patients own words

consent to treatment

legal forms that allow clinical services to be performed

consultations

narrative report made by another physician concerning a patient's condition

correspondence

letters and documents received from organizations

demographics

name, DOB, race, gender

diagnostic procedures

exams and analysis that assist the MD in diagnosis the patient's condition

discharge summary

summary of the significant events of a patient's hospitalization, must be completed and signed by the attending

emergency

prepared to document ED diagnosis and treatment

ethicolegal considerations

the patient owns the info in a medical chart however the physician owns the physical record

family history

review of the patients' blood relatives focuses on familial disease

health history

collection of subjective data about the patient (health status, diagnosis)

HIPPA

health insurance portability and accountability act

history of present illness

expansion of the cc full description of patient's current illness

history/physical report

must be performed on all inpatients, informs MD impression or diagnosis

home health care report

consists of care provided at patient's home

HPI OLDCART

onset, location, duration, contributing factors, associated factors, relieving factors, treatment

informed consent

nature of patient condition, nature of recommended treatments

inpatient

admission to the hospital for at least one overnight stay

laboratory results

a report of lab values associated with the analysis of body fluids

medical chart

a chronological system for recording each patient's medical care

medication record

contains detailed information concerning medications

operative report

completed for all surgical patients

past medical history

review of the patient's past health status

pathology report

gross and microscopic description of cells and tissues submitted for analysis usually includes diagnosis

patient registration

generally, includes demographic and billing information

physical examination

assesses the patient's body systems, provides objective data to inform diagnosis

POMR database

consists of a collection of subjective and objective data used to identify/compile a problem list

POMR plan

detailed description of diagnostic and treatment measures

POMR problem list

lists all of the patients' problems

POMR progress notes

includes the number of the problem followed by these four categories Subjective data Objective data Assessment Plan

progress notes

records updates in the patients' health status during visits and communications

release of information

legal forms that allow the release of health information to third parties

review of systems

a systematic review of each body system to reveal any issues not yet addressed

social history

focuses on lifestyle which may have an impact on the patients' health and wellbeing

therapeutic services

specialized assessments and care ordered by the MD (physical, speech therapy)