Chief complaint
Subjective statement about a patient's reason for visit made in the patient's own words.
Substance abuse
The use of a substance in a way that is not medically approved.
Addiction
A physical or psychological dependence on a substance. Involves and obsessive or compulsive preoccupation with the substance
6C's of charting
*client's word
*clarity
*completeness
*conciseness
*chronological order
*confidentiality.
Reverse chronological order
Type of charting where charts are arranged with the most recent information on top.
Methods of charting
SOAP
SOAP
*subjective
*objective
*assessment
*plan
Subjective data
Obtained from conversation with the patient or attending family member. It includes thoughts, feelings,perceptions & chief complaint.
Objective data
Readily apparent & measurable data. Eg vital signs.
Assessment
Physician's diagnosis or impression of the patient's problem.
Plan of action
Includes options for treatment, type of treatment chosen, medications, tests, consultations ect
SOMR
POMR
Computerized medical records
Three common methods for maintaining notes on a patient chart.
Source oriented medical records.
SOMR. Information is arranged according to who supplied the data.
Four components of POMR
Database
Problem list
Diagnostic & treatment plan
Progress notes
Database
Includes the patient's medical history, diagnostic & lab results & physical exam reports. This is the foundation of the problem-oriented medical record.
Problem list
Each patient condition or problem is listed individually, assigned a number & dated.
Diagnostic & treatment plan.
Lab & other diagnostic test are completed & the physician's treatment palm for the condition is documented.
Progress notes
The physician enters notes on every condition or problem recorded on the problem list. Notes are entered chronologically & include the CC, problems, conditions, treatments & responses to treatment.
Computerized medical records
Combination of SOMR & POMR but provides accessibility to anyone from a computer terminal. This enhances the patient's continuity of care between departments because everyone is looking at the same record.
Abnormal
Abnl
Antibiotics
Abx
Against medical advice
AMA
As much as possible
AMAP
Awake & oriented
A&O
Both
B
Biopsy
Bx
Childhood disease
CHD
Companies of
C/O
Cause of death
COD
Chest x-ray
CXR
Digital rectal exam
DRE
Headache
HA
History of
H/O
History & physical
H & P
Packs per day
PPD
No known allergies
NKA
Rule out
R/O
Sudden unexplained/unexpected death
SUD
Seizure
Sz
Polypharmacy
The administration of many drugs at the same time (to the same pt)
Patient oriented medical records
POMR. Used more exclusively in large clinics or practices that may have more than one physician who see the same patients. Problems are listed by date & numbered. It has four components, Database, Problem list, Diagnostic & treatment plan & Progress notes