Podcast
Questions and Answers
What is an allergy?
What is an allergy?
Acquired hypersensitivity to a substance (allergen) that does not normally cause a reaction.
What does CHEDDAR stand for in charting?
What does CHEDDAR stand for in charting?
Chief Complaint, History, Examination, Details of Problems and Complaints, Drugs and Dosages, Assessment, and Return Visit.
What is a chief complaint?
What is a chief complaint?
The specific reason, problem, or symptom that brought the patient to see the provider.
What is a clinical diagnosis?
What is a clinical diagnosis?
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What does 'objective' refer to in a medical context?
What does 'objective' refer to in a medical context?
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What is the Problem-Oriented Medical Record (POMR)?
What is the Problem-Oriented Medical Record (POMR)?
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What does SOAP/SOAPER stand for?
What does SOAP/SOAPER stand for?
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What is a Source-Oriented Medical Record (SOMR)?
What is a Source-Oriented Medical Record (SOMR)?
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What does 'subjective' mean in a medical context?
What does 'subjective' mean in a medical context?
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Study Notes
Definitions and Concepts in Patient History and Documentation
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Allergy: Hypersensitivity reaction to a normally harmless substance, referred to as an allergen.
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CHEDDAR: A detailed charting methodology encompassing:
- Chief Complaint
- History
- Examination
- Details of Problems and Complaints
- Drugs and Dosages
- Assessment
- Return Visit
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Chief Complaint: The primary issue or symptom prompting a patient to seek medical attention.
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Clinical Diagnosis: Determining a disease through patient history, laboratory tests, and observed symptoms.
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Objective: Observable signs of a patient's condition that can be measured or seen by a healthcare provider.
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Problem-Oriented Medical Record (POMR): A systematic record-keeping approach where vital patient identification data and medical problems are organized numerically for easy reference.
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SOAP/SOAPER: Framework for documenting patient progress notes that includes:
- Subjective impressions from the patient
- Objective clinical findings
- Assessment or diagnostic conclusion
- Plans for treatment
- Education provided to the patient
- Patient's response to care and education
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Source-Oriented Medical Record (SOMR): Record organization that categorizes patient information by source, such as lab reports and progress notes.
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Subjective: Symptoms experienced by the patient that are not externally observable, relying on the patient's own account.
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Description
Test your knowledge on patient history and documentation with this quiz based on Skills Chapter 23. From understanding allergies to the CHEDDAR charting approach, you'll reinforce your comprehension of essential medical terms and practices. Perfect for healthcare students and professionals alike.
