Across
- 1. primary care physcian
- 3. medical records also play an important role in medical research
- 5. subjective objective assessment plan
- 6. altering something to meet individual specification
- 8. able to trust the accuracy of the information in the medical records
- 9. audits government entities
- 11. electronic medical record
- 12. may be transmitted directly to the pharmacy
- 15. list each condition or diagnosis a patient has is listed separately and given its own number
- 17. medical records should be kept up to date
- 18. audits medical staff can perform internal audits
- 20. problem oriented medical record
Down
- 1. personal health record
- 2. progress notes are entered for each problem listed in the initial record
- 4. pertaining to data that are readily apparent and measurable
- 5. a subjective or internal condition felt by a patient
- 7. statistic data relating to the population and particular groups within
- 8. to examine and review a group of patients record for completeness and accuracy
- 10. is the process of recording information in the medical chart
- 13. record the clients exact words rather than your interpretation
- 14. the transforming of spoken notes into accurate written form
- 15. record/chart a compilation of important information about a patient's medical history and present condition
- 16. source oriented medical records
- 19. alert staff members about patients who require follow-up care
- 20. protective health information