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Cards In This Set
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Health Record
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Written or graphic record documenting facts and events during the care of patients.
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Contents of a Health Record
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Patient Registration Form
Medical Record History and Physical Examination Notes or Reports Progress or chart notes Consultation Reports Imaging and x-ray reports Laboratory reports Immunization Record Consent and Authorization Forms Operative Report Pathology Report |
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Contents of a Health Record in a Hospital setting
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Also includes:
Face Sheet Physician's Orders Discharge Summary Sheet |
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POR System
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Problem Oriented Record System
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POR Consists of
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Database
Problem List Plan Progress Notes |
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POR Sheets Also can Contain
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Record for blood sugar levels
Blood Pressure Weight Immunizations Medication Refilss |
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SOR System
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Source Oriented Record System
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SOR System are arranged according to the following system
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History and Physical Examination
Progress Notes Laboratory Tests Radiology Reports Surgical Operations |
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Integrated Record Filing System
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Documents are filed in reverse chronological order.
More difficult to locate data because they are scattered throughout the record. |
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EHR
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Electronic Health Record System
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The Electronic Health Record System is a collection of
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Medical Information about the past and present
Future Information Links data from many information systems |
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EHR vs EMR (Electronic Medical Record)
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EMR is the physician's individual electronic medical system
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Attending Physician
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Hospital Staff Member who is legally responsible for the care and treatment given to the patient.
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Consulting Physician
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Provider whose opinions are requested by another physician.
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The medical (health) record should be:
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Complete
accurate legible |
