CHAPTER 3 MEDICAL RECORDS QUESTIONS AND VERIFIED ANSWERS, 100%
GUARANTEE
Electronic medical record (EMRs) - The patient's medical record in digital format with
full interoperability within an enterprise like a hospital , clinic or practice.
Electronic health record (EHRs) - Often used interchangeably with electronic medical
record, however some health informatics specialists describe it as a generic term for all
electronic patient care systems.
Personal health record (PHR) - A copy of the patient's own medical Record that may be in
paper or digital format.
Concierge medicine - Practices in which patients pay a fee for special services such as
continuous access to medical records and the ability to email practitioners in the practice.
Health insurance portability and accountability act of 1996 (HIPAA) - Another name for
privacy act, act that governs and protects the handling of protected health information.
Important uses of medical record are - 1)To provide a means of communication through
providers.
2) to be used for financial purposes.
3) to serve as a legal document.
4) to be used as an educational tool
5) to provide statistical data for research purposes
Source-oriented medical record (SOMR) - The more traditional format used for recording
data in the medical record. Charts are divided into specific sections like history and physical ,
progress nots- notes that track the patients progress. There is no systemic cross-referencing for
this documentation format.
, Progress notes - Note that track's the patient's progress, The heart of the patient record ;
include physical notes about current problems and is chronological listing of the patient's overall
health status. usually in SOAP format.
(Reverse) chronological order - All reports and notes in the file/chart are kept most recent
notes on top
Problem-oriented medical record (POMR) or (POR) - Medical record documentation
format developed by Lawrence L. weed in the early 1970s that incorporates organized structure
within the medical chart.
POMR is developed using four categories or stages- - 1) develop a database
2) A simile a detail the problem list
3) formulate a plan of action for each problem
4) provide ongoing progress notes for each problem on the problem list.
Problem list - List of specific problems identified by the patient history that is placed at
the front of the patient's chart for easy referencing.
Subjective, Objective assessment, plan (SOAP) - Charting format used in the POMR, each
letter represents a different section of the document.
Subjective (S)
Part of SOAP - -Information provided by the patient.
-patient's chief complaint or reason for visiting in the patient's own words.
-person documenting the info is the medical assistant.
Objective (O)
Part of SOAP - -Something we can measure.(fever)
GUARANTEE
Electronic medical record (EMRs) - The patient's medical record in digital format with
full interoperability within an enterprise like a hospital , clinic or practice.
Electronic health record (EHRs) - Often used interchangeably with electronic medical
record, however some health informatics specialists describe it as a generic term for all
electronic patient care systems.
Personal health record (PHR) - A copy of the patient's own medical Record that may be in
paper or digital format.
Concierge medicine - Practices in which patients pay a fee for special services such as
continuous access to medical records and the ability to email practitioners in the practice.
Health insurance portability and accountability act of 1996 (HIPAA) - Another name for
privacy act, act that governs and protects the handling of protected health information.
Important uses of medical record are - 1)To provide a means of communication through
providers.
2) to be used for financial purposes.
3) to serve as a legal document.
4) to be used as an educational tool
5) to provide statistical data for research purposes
Source-oriented medical record (SOMR) - The more traditional format used for recording
data in the medical record. Charts are divided into specific sections like history and physical ,
progress nots- notes that track the patients progress. There is no systemic cross-referencing for
this documentation format.
, Progress notes - Note that track's the patient's progress, The heart of the patient record ;
include physical notes about current problems and is chronological listing of the patient's overall
health status. usually in SOAP format.
(Reverse) chronological order - All reports and notes in the file/chart are kept most recent
notes on top
Problem-oriented medical record (POMR) or (POR) - Medical record documentation
format developed by Lawrence L. weed in the early 1970s that incorporates organized structure
within the medical chart.
POMR is developed using four categories or stages- - 1) develop a database
2) A simile a detail the problem list
3) formulate a plan of action for each problem
4) provide ongoing progress notes for each problem on the problem list.
Problem list - List of specific problems identified by the patient history that is placed at
the front of the patient's chart for easy referencing.
Subjective, Objective assessment, plan (SOAP) - Charting format used in the POMR, each
letter represents a different section of the document.
Subjective (S)
Part of SOAP - -Information provided by the patient.
-patient's chief complaint or reason for visiting in the patient's own words.
-person documenting the info is the medical assistant.
Objective (O)
Part of SOAP - -Something we can measure.(fever)
