DEFINE THE PATIENT RECORD/CHART
WHAT IS DOCUMENTATION OF IMPORTANT INFORMATION ABOUT A PATIENT'S MEDICAL HISTORY AND PRESENT CONDITIONS SERVING AS BOTH A COMMUNICATION TOOL AND LEGAL RECORD
DESCRIBE THE FACETS OF A PATIENTS MEDICAL RECORD ?
*PERSONAL INFORMATION OR DATA
*PHYSICAL AND MENTAL CONDITION
*MEDICAL, FAMILY, AND SOCIAL HISTORIES
*MEDICAL CARE
*MEDICAL FUTURE IF THE PATIENT IS REFERRED TO OTHER PHYSICIANS
WHAT IS THE GENERAL INFORMATION IN THE PATIENTS MEDICAL RECORD ?
*ADDY AND PHONE NUMBER
*OCCUPOATION
*PATIENT MEDICAL HISTORY
*PAST, FAMILY, AND SOCIAL HISTORIES
*CURRENT COMPLAINT OR CONDITION
*HEALTH CARE NEEDS
*MEDICAL TREATMENT/PLAN OR SERVICES RECVD.
*MEDICAL IMAGING AND LABRATORY REPORTS
*RESPONCE TO CARE
DEFINE NONCOMPLIANT
WHAT IS A MEDICAL TERM USED TO DESCRIBE A PATIENT WHO DOES NOT FOLLOW THE MEDICAL ADVICE HE IS GIVEN
WHAT IS AN SOMR ?
WHAT IS A SOURCE ORIENTED MEDICAL RECORD
WHAT IS A SOURCE ORIENTED MEDICAL RECORD ?
THIS RECORD IS ARRANGED ACCORDING TO WHO SUPPLIED THE DATA - THE PATIENT THE DOCTOR SPECIALIST LABRATORY OR X RAY DEPARTMENT THIS FORM MAY HAVE SPACE FOR PATIENT REMARKS, FOLLOWED BY A SECTION FOR THE DOCTOR'S COMMENT
DEFINE POMR
WHAT IS A PROBLEM ORIENTED MEDICAL RECORD.
WHAT INFORMATION IS INCLUDED IN IT:
DATABSE
PROBLEM LIST
EDUCATIONAL
DIAGNOSTIC
TREATMENT PLANS
PROGRESS NOTES
WHAT IS A DATA BASE ?
THE DATA BASE INCLUDES A RECORD OF THE PATIENTS HISTORY, INFORMATION FROM THE PATIENTS INITIAL INTERVIEW, ALL FINDINGS AND RESULTS FROM PHYSICAL EXAMS BLOOD TESTS X RAYS OR OTHER PROCEDEURES
WHAT IS A PROBLEM LIST ?
EACH PROBLEM (CONDITION/DIGNOSIS) A PATIENT HAS IS LISTED SEPERATELY, GIVEN ITS OWN NUMBER, AND DATED. WHEN DOCUMENTING PROBLEMS BE CAREFUL TO DISTINGUISH BETWEEN THE PATIENTS SIGNS AND SYMPTOMS
DEFINE A SIGN ?
WHAT IS AN OBJECTIVE OR EXTERNAL FACTOR SUCH AS ELEVATED BP, RASH, SWELLING THAT CAN BE SEEN OR FELT BY THE PHYSICIAN OR MEASURED BY AN INST