Chapter 5
The CHEDDAR method – this method of entry uses the same information as the SOAP method and places it under seven headings: What are the 7 headings?
C (chief complaint) H (history of the present illness) E (examination) D (details of problems and complaints) D (drugs and dosage – past and current medications) A (assessment) R (return visit or referral to a specialist)
For how long should a medical facility hold medical records of a minor
Patient health records (minors): Age of majority (varies between 18 and 21 years of age) plus statute of limitations on malpractice; in most states, the time period ranges from one to four years.
What does POMR stand for
Problem-Oriented Medical Records
Who owns medical records?
According to the Council, medical notes made by a physician—the actual chart notes, reports, and other materials—are the physician’s property.
Name the classification of files
Active, Inactive and Closed files
Patient health records (competent adults): Ten years after patient’s most recent encounter.
Patient health records (incompetent adults): (a) until the patient becomes competent, then following the guideline for a competent adult; (b) 7 years after the patient’s death; or (c) indefinitely.
What is the abbreviation for Diagnosis