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Should A problem list is used with which type of medical record format?
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What kind of record format consists of format databases problem lists initial plans and progress notes?
The record format you are referring to is likely the SOAP note format used in medical documentation. SOAP notes include subjective information (S), objective data (O), assessments (A), and plans (P), making it a structured format for healthcare professionals to document patient encounters.
What is not a traditional health record format?
EMR- Electronic Medical record
Differences between source oriented problem oriented medical record?
In a POMR or problem oriented medical record, the record is kept together by problem number (a number is assigned to each problem. Progress notes in these records are kept in SOAP format. S=subjective (chief complaint, present illness), O=objective (physical exam, labs), A=assessment (diagnosis, prognosis), P=plan (treatment). In a SOMR or source oriented medical record, the record is kept together by subject matter (labs are all together, progress notes are all together). Progress notes in a SOMR are written in paragraph format.
What actions should be taken if you identify an error in a patients medical record?
No deletions should be made, as the medical record is also a legal document. But an amending notation should be made and added to the medical record.
What are some of the problems with poor medical record keeping in hospitals?
Illegible notes constitutes one of the major contributors to poor medical records. Too much paper is another problem. Electronic medical record keeping should improve both problems.
Which medical record system has a standard format that makes it easy to read and audit?
progress note
Why should a recording in the medical record never be erased or abliterated?
The medical record is a legal document.
What should you use When indicating the exact words of a patient on a medical record?
Quotation marks should be used when indicating a patient's exact words on a medical record.
The medical record should be released only with a?
Medical records are confidential. They should only be released after the patient has signed a release form.
How long are doctors required to keep medical records in Connecticut?
How long should a medical record be retained
If a code is not documented in medical records the medical assistant should never code a patient as having what?
a medical assistant should never code a patient as having what unless its is documented in medical record
How long should medical records be kept?
Medical records should be kept for as long as required based on the type of record, and federal/state laws.
