Miscellaneous Vocabulary Flashcards Preview

Data Analysis > Miscellaneous Vocabulary > Flashcards

Flashcards in Miscellaneous Vocabulary Deck (7)
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1
Q

Source Oriented Record (SOR)

A

Maintains reports according to source documentation (i.e. Nursing notes, radiology, lab reports are all group together according to department)

2
Q

Problem Oriented Record (POR or POMR)

A

More systematic method of documentation, which consists of four components: Database, Problem List, Initial Plan & Progress Notes

3
Q

Integrated Record

A

Usually arranges reports in strict chronological date order

4
Q

SOAP Structure: S - Subjective

A

Patient’s statement about how she feels, including symptomatic information

5
Q

O - Objective

A

Observations about the patient, such as physical findings or lab or x-ray results (i.e. Chest x-ray negative)

6
Q

A - Assessment

A

Judgement, opinion, or evaluation made by the health care provider (i.e. acute migraine)

7
Q

P - Plan

A

Diagnostic, Therapeutic, and educational plans to resolve the problems (i.e. patient to take Tylenol as needed for pain)