CHAPTER 9 TERMS

To examine and review a group of patients' records.

The format of medical records documentation takes the SOAP format further. Stands For: Chief complaint, History, Examination, Details, Drug and dosage, Assessment, Return visit

The recording of information in a patient's medical record; includes detailed notes about each contact with the patient and about the treatment plan, patient progress, and treatment outcomes.

Patient health record created and stored on a computer or other electronic storage device. Also known as electronic medical records.

Patient medical record created and stored on a computer or other electronic storage device.

Any part of an individual's health information, including demographic information, collected from an individual that is received by a covered entity. ( health care provider)

A form that verifies that a patient understands the offered treatment and its possible outcomes or side effects.

Describes a patient who does not follow the medical advice given

Pertaining to data that is readily apparent and measurable, such as vital signs, test results, or physical examination findings.

A compilation of important information about a patient's medical history and present condition.

The problem oriented medical record system- for keeping patients' charts. Information in a POMR includes the database of information about the patient and the patient's condition, the Problem list, the diagnostic and treatment plan, and progress notes.

An objective or external factor, such as blood pressure, rash, or swelling, that can be seen or felt by the physician or measured by an instrument.

An approach to medical records documentation that documents information in the following Order: S(subjective data), O(objective data), A(assessment), P(plan of action)

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

A subjective, or internal, condition felt by a patient, such as pain, nausea, or something the doctor cannot see nor measure.

The transforming of spoken notes into accurate written form.

To give something, such as information, to another party outside the doctor's office.