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SOAP notes - 🧠 ANSWER ✔✔subjective, objective, assessment, plan
EMR - 🧠 ANSWER ✔✔electronic medical record
more narrowly focused detailed history
EHR - 🧠 ANSWER ✔✔electronic health record
more broad "snap shot" of history
popular EHR companies - 🧠 ANSWER ✔✔cerner, epic, all scripts
paper vs electronic documentation - 🧠 ANSWER ✔✔if providers can show
meaningful use they can get financial support
,government incentives to switch to electronic documentation - 🧠 ANSWER
✔✔3 phase program
began in 2011-2012
medical history form - 🧠 ANSWER ✔✔longer version of health history form
can be filled out by the individual or they can be asked questions
use judgement
ask if they would like assistance
health screening form - 🧠 ANSWER ✔✔shorter version of medical history
form
not to be used with high risk patient or patient with doctor prescribed
exercise
, informed consent document should include - 🧠 ANSWER ✔✔purpose and
explanation of the test
clients risks and discomforts
responsibilities of the client
benefits to be expected
inquiries
use of medical records
freedom of consent
physician release forms - 🧠 ANSWER ✔✔not needed by those that do not
need medical clearance
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