Chapter 11 Medical Records & Documentation Key Terms – Flashcards
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Audit
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To examine and review a group of patient records for completeness and accuracy - particularly as related to their ability to back up the charges sent to health insurance carriers for reimbursement.
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CHEDDAR
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C: Chief Complaint. H: History. E: Examination. D: Details of Problem and Complaints. D: Drugs and Dosage. A: Assessment. R: Return visit information or referral; if applicable.
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Demographics
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Statistical data relating to the population and particular groups within it.
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Documentation
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The recording of information in a patient's medical record; includes detailed notes about each contact with the patient and about the treatment plan, patient progress, and treatment outcomes.
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Noncompliant
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The term used to describe a patient who does not follow the medical advice given.
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Objective
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Pertaining to data that are readily apparent and measurable, such as vital signs, test results, or physical examination findings.
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Patient Record/Chart
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A compilation of important information about a patient's medical history and present condition.
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Problem Oriented Medical Record or "P.O.M.R"
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Developed by Lawrence L. Weed, MD, this system makes it easier for the physician to keep track of a patient's progress. It includes the database of information about the patient and the patient's condition, the problem list, the diagnostic and treatment plan, and progress notes.
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Review of Systems or "R.O.S"
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A process of gathering information about a patient's health history regardless of apparent relevance to the chief complaint.
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Sign
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An objective or external factor, such as blood pressure, rash, or swelling, that can be seen or felt by the physician or measured by an instrument.
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Subjective, Objective, Assessment, Plan; or SOAP
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An approach to medical records documentation that documents information in the following order: S: Subjective Data, O: Objective Data, A: Assessment, P: Plan of Action.
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In "SOAP" the letter "S" means...
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Subjective data comes from the patient; describing their signs and symptoms.
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In "SOAP" the letter "O" means...
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Objective data comes from the physician, examinations, and test results.
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In "SOAP" the letter "A" means...
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Assessment is the diagnosis or impression of the patient's problem.
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In "SOAP" the letter "P" means...
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Plan of action includes treatment options, chosen treatment, medications, tests, consultations, patient education, and follow-ups.
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Source Oriented Medical Record or "S.O.M.R"
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Patient information is arranged within the chart or medical record according to who supplied the data - The Patient, Treating Physician, Specialist, Hospital, Lab, or other location.
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Subjective
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Pertaining to data that are obtained from conversation with a person or patient.
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Symptom
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A subjective, or internal, condition felt by a patient, such as pain, headache, or nausea, or another indication that generally cannot be seen or felt by the doctor or measured by instruments.
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Transcription
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The transforming of spoken notes into accurate written form.
