Flashcards in Diagnostic & Treatment Deck (85)
X-ray (roentgenograms) scientists is credited with the discovery of x-ray.
Process of cleaning or freeing materials from dirt. (sanitization can be the first step in the process of preparing instruments for sterilization and includes cleaning grossly visible materials from the surface).
Is the method used for complete destruction of microorganisms and their spores.
Process of measuring.
Is examining through feel.
Is resonance of sounds within the body.
Vital signs measurements
Temperature, Pluse, Respiration (TPR) and blood pressure (BP) are vital signs measurements.
Review Of System (ROS)
Questions regarding each of the major body systems and parts.
- Is the chronological system for recording each patient's medical records.
- Purpose: To establish a database on each patient consisting of information concerning the patient's life, history, illness and treatment.
Medical chart- Chief complain (CC)
- Primary reason for seeking medical care.
Medical chart- Past medical history (PH/PMH)
Past medical history:
- This document may be prepared by the MA, provider, or patient. Questions relate to usual childhood disease (UCD), past illnesses, past surgeries, and current health status.
Medical chart- Family history (FH)
- Includes details regarding the patient's parents and siblings such as health status, age and causes of death, hereditary disease, etc.
Medical chart- Present illness (PI)
- Details associated with the chief complaint.
Medical chart- Social history (SH)
Information regarding personal habits such as exercise, sleep, diet, alcohol/tobacco/drug use, sexual activity, hobbies, etc.
Medical chart- Occupational history (OH)
- Information regarding the patient's employment.
Medical chart- Physical examination (PE)
- A complete physical exam may be performed to assess the status of each body system. this documentation will serve as a base reference for future diagnosis and treatment.
Medical chart- Diagnostic and laboratory tests
Test results are usually arranged in reverse chronological order.
Medical chart- Consultation reports
Evaluations made by other practitioners at the request of the provider.
Medical chart- Correspondence
As related to the patient's care.
Medical chart- Providers notes
Notes written in the chart by the health care provider regarding a patient's diagnosis and treatment.
Medical chart- Termination summary
Documents that serve to identify discontinuation of care either by a consulting or primary provider.
Medical chart- Source
Medical data are characterized by it's source:
- Medical history
- Progress notes
- Diagnostic reports
Problem Oriented Medical Record (POMR)
Medical data are organized and identified according to disease, situation, or condition.
- Problem list
- Progress notes
Includes the patient's history, chief complaint, physical exam findings, and laboratory results. An additional page is prepared for each condition requiring diagnosis and treatment.
POMR- Problem list
Consist of physical, psychological, and social problems related to the condition. The chart may distinguish between short-and long-term problem lists.
Detailed description of diagnostic and treatment measures to include instruction, teaching and perhaps further evaluations.
POMR- Progress notes
Uses the SOAP approach.
- Subjective data
- Objective data
- Assessment (S + O)
- Plan (S + O + A)
POMR- Subjective data
Related to the patient's signs, symptoms and feelings as described by the patient.