Examlex
Data from the accounting department that have been collected previously for another purpose are an example of ____________________.
SOAP
An approach to medical records documentation that documents information in the following order: S (subjective data), O (objective data), A (assessment), P (plan of action).
Documentation
Written or printed material that provides official information or evidence, or that serves as a record.
Problem-Oriented Medical Record (POMR)
A method of recording healthcare information that organizes data by the patient's specific problems, facilitating a systematic approach to treatment.
Initial Interview
The first meeting between a healthcare provider and a patient, aimed at discussing health concerns and medical history.
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