Chemistry/ Parts of a cell
charting
EHR
parts of an interview
SOAP note
100

Performs cellular respiration 

Mitochondria 

100

order you alphabetize a name

Last name first, then first name, then middle initial

100

examples include password, fingerprints, badge ID

authentication 

100

a medical history is obtained

prior to admission

100

c/o 8/10 pain in shoulder 

S-Subjective 

200

makes energy for the cell

carbohydrates 

200
growth chart is an example of 

flow chart

200

turns data into an unreadable format

encryption 

200

reason the person came into the visit

CC- Chief complaint 

200

X-Ray ordered of R shoulder

P-Plan

300

Building blocks of tissue

Protiens

300

placing the newest documents in front and the oldest in the back

reverse chronological 

300

protects computer from unauthorized access 

firewall 

300

examples include DOB, SSN, name

personal data

300

r/o MI

A-Assessment

400

bleach is an example of 

base

400

patient information sheet contains 

personal and insurance information 

400

chart is divided based on department, facility, or source that generated the information

Source oriented record 

400

includes: marital status, occupations, use of chemical substances

social and occupational history 

400

abrasion noted to R elbow, measuring 3 cm x 6 cm, with serosanginous drainage, pink wound bed, slight erythema in surrounding tissue 

O- Objective 

500

makes cell membranes 

phospholipids 

500

the 6 C's of charting

conciseness, confidentiality, client's words, clarity, chronological order, completeness 

500

problems are assigned a number and that number is referenced each time that patient is seen 

Problem Oriented Medical Record (POMR or POR)

500
When obtaining a history, as these type of questions

open-ended

500

SOAP stands for

subjective, objective, assessment, and plan

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