Examlex
Showing through non-evaluative verbal responses that you have listened to what the employee has stated is:
SOMR
Source-oriented medical record.
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.
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