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Cliff Is 16 Years Old, Is Truant from School, Drinks

question 115

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Cliff is 16 years old, is truant from school, drinks alcohol regularly, and has run away from home. Legally speaking, Cliff is a(n)


Definitions:

Source-Oriented Medical Records

Medical records organized according to the source of the information, making it easier to track data from different healthcare providers.

Patient Chart

A comprehensive record maintained by a healthcare provider detailing the history, diagnosis, treatment, and medical care of a patient.

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.

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