Tag: Patient documentation

Developed in the 1960s, the problem-oriented medical record (POMR) was designed to provide a more logical and structured approach to patient documentation. This systematic method organizes a patient's entire health information based on a specific set of problems rather than a chronological timeline. So, which information is part of a problem-oriented medical record?

According to research published by the National Center for Biotechnology Information, the astute observation of a patient's general appearance can provide crucial diagnostic clues to underlying conditions. Understanding how to describe patient physical appearance is therefore a fundamental skill for any healthcare provider, ensuring clear and objective documentation that supports effective care.

According to the Nurses Service Organization (NSO), documentation errors or omissions were found in a significant number of liability claims against nurses. This underscores precisely why is it important to document how the patient responded to the procedure, ensuring clarity, accountability, and the best possible outcome for every individual under care.

Proper neurovascular assessment documentation is critical, particularly following trauma or surgery. The phrase **what does NV intact mean in medical terms** refers to a notation confirming a patient’s nerve and vascular function in a specific area is fully normal, with no signs of compromise.

According to a 2022 survey, outpatient visits significantly outnumber inpatient hospital stays, highlighting the importance of understanding medical documentation in both settings. The setting of your care has major implications for your medical documentation, dictating the content, detail, and purpose of your records. This can be critical when answering the question: **What's the difference between inpatient and outpatient medical reports?**

According to research, the SOAP note, a structured method for documenting patient encounters, has been used since the 1960s to standardize clinical records. This popular medical mnemonic for SOAP provides a clear framework for communication among healthcare professionals, ensuring comprehensive and consistent patient care.

An impending or threatened condition refers to a situation where a medical condition has not yet fully developed but is strongly suspected based on clinical evidence. Understanding the specific meaning of an impending condition is crucial for accurate medical coding, diagnosis, and patient management.