Medical Records
Type of vaccine received, date of administration and any adverse reactions
What is an immunization record?
Contain information about a patient's surgery and surgical history
What is a surgical report?
EHR's
What are Electronic Health Records?
This contains patient information collected over time
What is a medical record?
Next steps for patient
What is plan?
Contains prescribed medications, dosages and duration
What is a prescription record?
Contain information about imaging results
What are radiology reports?
SOAP
What is Subjective, Objective, Assessment and Plan
This is specific for a single test, screening or procedure
What is a medical report?
Based on patient's description
What is subjective?
These contain information which goes into a patient's medical record
What is a patient form?
Summarize the analysis of removed tissue, blood or organ
What is a pathology report?
UTI
What is Urinary Tract Infection?
The patients reason for a visit
What is chief complaint?
Results of a patient evaluation
What is assessment?
Medical records stored electronically
What are Electronic Health Records?
Genetic tests, mammograms and colonoscopy's are found in this type of report
What is a screening report?
Rx
What is prescription?
This type of note has information compiled in chronological order
What is a narrative note?
Based on a provider's observation and evidence
What is objective?
This may include personal information, chief complaint, current medical condition, medications, allergies and medical history
What is a patient data form?
Contains results of blood tests, urine tests, and pathogen cultures
What is a diagnostic report?
What is chief complaint?
Tell me 5 specific symptoms regarding your assigned illness
What is?
A benefit of SOAP notes
What is they eliminate excess writing and reading?