| A | B |
|---|
| paper-based | patient medical information that is written by the provider on hard copy or paper and filed in a record |
| computer-based | patient medical record infomation that is entered by a provider via computer hardware |
| SOAP note | template used by providers to enter patient information and treatment progress notes |
| Subjective | originated from patient, based on their chief complaint |
| Objective | originated from the physician objective or empirical information |
| Assessment | diagnosis |
| Plan | prescriptions, additional tests or therapists, and follow-up visits |
| Progress notes | written description on what occured during the patient encounter/visit |
| Physicians' reports of evaluation/examination | after the physician has examined the patient, the findings are documented within this report |
| Surgery reports | also called procedural or operative reports- description of operation or procedure |
| Radiology/Lab results | results of diagnostic x-ryas, CT scans, MRI's, Sonograms, etc |
| Lab tests | specimens (blood/fluid) removed from the patient for diagnostic purposes |
| Correspondence | information concerning that patient via the mail or electronic media. Can be treatment, administrative, or financially related. |
| Altering a medical record | draw a line through the error, insert correction above/beside the error, date |
| How frequently should documentation be filed in a medical record? | daily |
| Active Record | patient's current medical record information |
| Inactive Record | patient has not been seen within three years |
| Federal law requires medical records be kept for how many years? | 7 years |
| Federal law requires pediatric medical records be kept for how many years? | 7 years past date of majority |
| demongraphic | specific information required of a population |
| POMR | patient-oriented medical record |
| SOMR | source-oriented medical record |
| sign | an objective, or external factor such as blood pressure |
| symptom | a subjective, or internal factor such as patient complains of pain |
| noncompliant | term used to describe a patient who does not follow medical advice |
| documentation | process of recording information in the medical record |
