Chapter 11 Medical Records & Documentation Key Terms

Chapter 11 Medical Records & Documentation Key Terms

Audit
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.
CHEDDAR
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.
Demographics
Statistical data relating to the population and particular groups within it.
Documentation
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.
Noncompliant
The term used to describe a patient who does not follow the medical advice given.
Objective
Pertaining to data that are readily apparent and measurable, such as vital signs, test results, or physical examination findings.
Patient Record/Chart
A compilation of important information about a patient’s medical history and present condition.
Problem Oriented Medical Record or “P.O.M.R”
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.
Review of Systems or “R.O.S”
A process of gathering information about a patient’s health history regardless of apparent relevance to the chief complaint.
Sign
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.
Subjective, Objective, Assessment, Plan; or SOAP
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.
In “SOAP” the letter “S” means…
Subjective data comes from the patient; describing their signs and symptoms.
In “SOAP” the letter “O” means…
Objective data comes from the physician, examinations, and test results.
In “SOAP” the letter “A” means…
Assessment is the diagnosis or impression of the patient’s problem.
In “SOAP” the letter “P” means…
Plan of action includes treatment options, chosen treatment, medications, tests, consultations, patient education, and follow-ups.
Source Oriented Medical Record or “S.O.M.R”
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.
Subjective
Pertaining to data that are obtained from conversation with a person or patient.
Symptom
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.
Transcription
The transforming of spoken notes into accurate written form.