1. medical problems of siblings and parents:
c] family history
2. expansion of information that brought the patient to the office:
a] history of present illness
3. all health problems, illnesses, and surgeries:
b] medical history
4. occupation, hobbies, and drug habits:
d] social history
What are source oriented medical records quizlet?
A source-oriented record is one in which each healthcare group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x- ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. [
Which among the following is the best description of a problem
Which of the following is the best description of a problem-oriented medical record? Items of the same medical condition are filed together.
What is the purpose of source oriented medical record?
Source-oriented [SO] charting is a narrative recording by each member [source] of the health care team charts on separate records. SO charting is time-consuming and can lead to fragmented care. Problem-oriented medical record [POMR] charting was introduced by Dr. Lawrence Reed to focus on the client's problem.
How does the source oriented medical record work quizlet?
Source Oriented Medical Record - documents grouped according to their point of origin. i.e., lab records together, radiology together, clinical notes, and so on. Thus, physicians progress notes for a single episode of patient care are arranged usually in reverse chronological order, and filed together in MR.