Examlex
If Bill tells Sara that he will give her two days to decide if she wants to buy his car,he cannot sell it to anyone else during that time.
POMR
The problem-oriented medical record system is for keeping patients' charts. Information in a POMR includes the database of information about the patient and the patient's condition, the problem list, the diagnostic and treatment plan, and progress notes.
SOAP Records
An acronym that stands for Subjective, Objective, Assessment, and Plan, which outlines a method of documentation used by healthcare professionals to record patient information.
Health History Form
A document that details an individual's medical history, used by healthcare providers to assess patient health and make informed treatment decisions.
Family History
The record of diseases or health conditions in the relatives of an individual, which can impact their risk of developing similar conditions.
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