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The objective of a medical record is to provide a comprehensive and accurate account of a patient's medical history, treatments, and outcomes. It serves as a crucial tool for healthcare providers to ensure continuity of care, facilitate communication among medical professionals, and support clinical decision-making. Additionally, medical records are essential for legal documentation, billing purposes, and research. Ultimately, they aim to enhance patient safety and improve overall healthcare quality.
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What is the form in the medical record that contains subjective info about the patient's past illness?
The form in the medical record that contains subjective info about the patient's past illness is called a SOAP note. SOAP is the acronym for subjective, objective, assessment, and plan.
What are the importance of medical record keeping?
The importance of medical record keeping is keeping a treatment record of a patient that allows medical professionals to know the patient's past
What is the medical term meaning record of the eardrum?
Tympanogram is the medical term for a record of the eardrum.
What is the medical term meaning RECORD of the LUNG?
A pneumogram is the medical term meaning record of the lung.
Why should a recording in the medical record never be erased or abliterated?
The medical record is a legal document.
What is the medical term meaning record of a breast?
Mammogram is the medical term meaning record of a breast.
What kind of record format consists of format databases problem lists initial plans and progress notes?
Medical records at Willow Nursing Home have the following format: database, problem list, initial plan, and progress notes. What type of record format is this? This type of record format is called C. Problem-oriented
A medical record is an example of?
A person's (patient) medical record is the history of what medical illnesses and the medicine prescribed the person received to date.
What is the prime objective of the medical profession?
render service to humanity
For the court's purpose if documentation does not appear in the medical record?
For the court's purpose, if documentation does not appear in the medical record
What is the medical term meaning record of muscle electricity?
Medical term for record of electricity is electromyogram
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.
