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Medical DocumentationMedical Documentation

QURATULAIN MUGHALQURATULAIN MUGHAL

BATCH IVBATCH IV

IIRSIIRS

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Medical DocumentationMedical Documentation

Medical documentation refers to any Medical documentation refers to any written or electronically generated written or electronically generated information about a client describing information about a client describing services or care provided to that services or care provided to that client.client.

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Electronic documentsElectronic documents

Electronic documents include Electronic documents include computer created medical record computer created medical record files, faxes, e-mails, pictures, video files, faxes, e-mails, pictures, video or audio recordings.or audio recordings.

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PurposePurpose

The primary purpose of medical The primary purpose of medical documentation is to establish that documentation is to establish that individual's health status and need for individual's health status and need for care, record the care given, and care, record the care given, and demonstrate the results of the care.demonstrate the results of the care.

Medical documentation allows for the Medical documentation allows for the exchange of information between all exchange of information between all members of the healthcare team. members of the healthcare team.

The health record provides legal proof of The health record provides legal proof of the type of care the patient received and the type of care the patient received and that person's response to that care.that person's response to that care.

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TYPES OF MEDICAL RECORD TYPES OF MEDICAL RECORD DOCUMENTATION DOCUMENTATION

There are various forms of medical record There are various forms of medical record documentation :documentation :

PROBLEM ORIENTED MEDICAL PROBLEM ORIENTED MEDICAL RECORD(POMR) RECORD(POMR)

PROGRESS NOTE PROGRESS NOTE SOAP SOAP NARRATIVE FORMAT NARRATIVE FORMAT DAP (DATA, ASSESSMENT, PLAN)DAP (DATA, ASSESSMENT, PLAN) ADIME (Assessment, Diagnosis ADIME (Assessment, Diagnosis

Intervention, Monitoring, Evaluation)Intervention, Monitoring, Evaluation)

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PROBLEM ORIENTED MEDICAL PROBLEM ORIENTED MEDICAL RECORD(POMR)RECORD(POMR)

A system of collection data that A system of collection data that focuses on the primary client focuses on the primary client problems.problems.

A problem list is generated, A problem list is generated, updated, and continually reviewed updated, and continually reviewed

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PROGRESS NOTE PROGRESS NOTE

Often a brief notation as a follow up Often a brief notation as a follow up to an original assessment. to an original assessment.

This note will review the problem, This note will review the problem, evaluate the effectiveness of plan, evaluate the effectiveness of plan, and indicate change. and indicate change.

Progress notes are documented at Progress notes are documented at pre-established intervals (daily, twice pre-established intervals (daily, twice a week, monthly, etc) a week, monthly, etc)

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SOAP SOAP

Acronym for Subjective, Objective, Acronym for Subjective, Objective, Assessment, Plan.Assessment, Plan.

Many physicians and health care Many physicians and health care providers document in this format providers document in this format and it is easy to follow.and it is easy to follow.

Some facility use pre-printed forms Some facility use pre-printed forms and practitioners fill out the blanks. and practitioners fill out the blanks. Others simply provide lined sheets Others simply provide lined sheets that the provider will simply write out that the provider will simply write out ..

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NARRATIVE FORMAT NARRATIVE FORMAT

The provider writes out information The provider writes out information about the patient in an organized about the patient in an organized way (similar data clustered way (similar data clustered together). together).

Often this is in long phrases or Often this is in long phrases or sentences reviewing the patient’s sentences reviewing the patient’s problems. problems.

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DAP (DATA, ASSESSMENT, DAP (DATA, ASSESSMENT, PLAN) PLAN)

Similar to SOAP but without the Similar to SOAP but without the subjective component (all data, subjective component (all data, whether subjective or objective is whether subjective or objective is clustered together) clustered together)

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ADIME (Assessment,Diagnosis ADIME (Assessment,Diagnosis Intervention,Monitoring,Evaluation )Intervention,Monitoring,Evaluation ) This type of charting follows the This type of charting follows the

Nutrition Care Process steps Facilities Nutrition Care Process steps Facilities may decide to order notes in this may decide to order notes in this format OR address the initial problem format OR address the initial problem of the patient (in acute care) of the patient (in acute care)

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