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| Pregunta | Respuesta |
| Source- Oriented Medical Record (SOMR) | more traditional format used for recording data -divided into specific sections: history and physical, progress notes, nursing/medical assisting notes, laboratory, and diagnostic testing *progress notes are usually recorded in a narrative format *all reports and notes are kept in reverse chronological order |
| Problem-Oriented Medical Record (POMR) | -created in 1970s by Lawrence L. Weed; POR -Database: patient history, physical findings, and baseline readings for testing -Detailed problem list: records specific problems , should list any new problems -A plan of action for each problem. |
| Subjective, Objective, Assessment, Plan (SOAP) | the POMR system uses the SOAP system -Subjective: info provided by patient -Objective: info provider by professional -Assessment: interpretation of findings _Plan: the providers plan |
| Contents of the Medical Record | - physician's personal preference -type of practice -cost of supplies -regulatory requirements |
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