Problem-oriented Medical Record Concepts |
Contents
PROBLEM LIST CONCEPTS | 24 |
DATABASE CONCEPTS | 51 |
THE COMPONENTS OF A PATIENT CARE NOTE | 76 |
Copyright | |
6 other sections not shown
Common terms and phrases
abbreviations able abnormal action ACTIVE acute adaptations addition answer Appraisal approach audit become begin Chapter chart chest pain collected communication complaint complete component concept contain contents database DATE DB-H DB-HPI DB-PE DB-T defined determined diagnostic discharge discussed doctor entered examination example fact Figure flow sheet four frequently functions give given going Headache hospital identified important INACTIVE included information units major medical record medicine MICHIGAN myocardial infarction NAME nurse Objective ONSET organized pain paramedical patient care note percent physical physician presentation Problem List problem-oriented progress notes Pyuria question random reader refer resolved routine simple situation specific status studies style Subjective summary taking task tests therapeutic things understand unit value UNIVERSITY usually writing written X-ray