Skills Chapter 23 Patient History Quiz

Definitions and Concepts in Patient History and Documentation

• Allergy: Hypersensitivity reaction to a normally harmless substance, referred to as an allergen.

• CHEDDAR: A detailed charting methodology encompassing:

  • Chief Complaint
  • History
  • Examination
  • Details of Problems and Complaints
  • Drugs and Dosages
  • Assessment
  • Return Visit

• Chief Complaint: The primary issue or symptom prompting a patient to seek medical attention.

• Clinical Diagnosis: Determining a disease through patient history, laboratory tests, and observed symptoms.

• Objective: Observable signs of a patient's condition that can be measured or seen by a healthcare provider.

• Problem-Oriented Medical Record (POMR): A systematic record-keeping approach where vital patient identification data and medical problems are organized numerically for easy reference.

• 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

• Source-Oriented Medical Record (SOMR): Record organization that categorizes patient information by source, such as lab reports and progress notes.

• Subjective: Symptoms experienced by the patient that are not externally observable, relying on the patient's own account.