Problem Oriented Medical Record definition
Problem Oriented Medical Record format is utilized throughout ▇▇▇▇▇ County system. The health record will contain the following information: ● Identifying information (e.g. inmate name, alias, ID #, date of birth) ● Completed Receiving Screening form ● Medical Evaluation Report ● All findings, diagnosis treatments and dispositions ● Problem list ● Medication Administration Record ● Laboratory, X-ray and diagnostic studies ● Signed Informed Consent ● Refusal forms ● Place, date and time of all health encounters ● Dental consultations/treatments ● Psychiatric evaluations and treatments ● Hospital Discharge Summaries ● Transfer forms ● Individual treatment plans as required ● Allergy alert
Examples of Problem Oriented Medical Record in a sentence
The "Problem Oriented Medical Record" format is utilized throughout CONTRACTOR system.