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20 Cards in this Set
- Front
- Back
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Patient's chart:
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Medical Record
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chronological system used to annotate patient's medical care that the health care provider renders.
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medical record
(legal document) |
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Main reason for the patient seeking care.
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chief complaint (CC)
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gives info regarding usual childhood diseases (UCD), past illnesses, surgeries, and current health status; may be prepared by pt, HCP, or MA
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past medical history (PH/ PMH)
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info regarding the pt's parents and siblings; may include health status, age, cause of death, and hereditary diseases
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family history (FH)
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expanded CC (chief complaint)
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present illness (PI)
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info on pt;s personal habits; may include exercise, sleep, diet, tobacco and/or alcohol use, drug use, sexual history, sexual preference, and hobbies
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social history (SH)
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info regarding pt's employment
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occupational history (OH)
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complete physical exam; gives info regarding each system (ROS); may serve as a baseline against the future
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physical examination (PE)
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diagnostic and laboratory tests; arranged with most recent at top
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test results
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reports on evaluations made by other health care providers
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consultations
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records from other health care providers that have bearing on present treatment
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past medical records
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all correspondence related to pt care
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correspondence
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notes written in the chart by the HCP regarding the pt's care, dx, and tx
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progress notes
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record of all medications and prescriptions given or renewed in the office
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medication/ prescription record
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record of all immunizations administered in the office
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immunization record
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what are the 2 forms of record organization?
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source-oriented and problem-oriented
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observations and data are categorized by their source; filed in reverse chronological order
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source-oriented record
(ie: HCP, laboratory, radiography, nurse) |
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POMR
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problem-oriented medical record
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data organize according to pt's disease or condition; divided into 4 parts
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problem-oriented medical record
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