Chemistry/ Parts of a cell
Performs cellular respiration
Mitochondria
order you alphabetize a name
Last name first, then first name, then middle initial
examples include password, fingerprints, badge ID
authentication
a medical history is obtained
prior to admission
c/o 8/10 pain in shoulder
S-Subjective
makes energy for the cell
carbohydrates
flow chart
turns data into an unreadable format
encryption
reason the person came into the visit
CC- Chief complaint
X-Ray ordered of R shoulder
P-Plan
Building blocks of tissue
Protiens
placing the newest documents in front and the oldest in the back
reverse chronological
protects computer from unauthorized access
firewall
examples include DOB, SSN, name
personal data
r/o MI
A-Assessment
bleach is an example of
base
patient information sheet contains
personal and insurance information
chart is divided based on department, facility, or source that generated the information
Source oriented record
includes: marital status, occupations, use of chemical substances
social and occupational history
abrasion noted to R elbow, measuring 3 cm x 6 cm, with serosanginous drainage, pink wound bed, slight erythema in surrounding tissue
O- Objective
makes cell membranes
phospholipids
the 6 C's of charting
conciseness, confidentiality, client's words, clarity, chronological order, completeness
problems are assigned a number and that number is referenced each time that patient is seen
Problem Oriented Medical Record (POMR or POR)
open-ended
SOAP stands for
subjective, objective, assessment, and plan