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review of systems
inquires about the system directly related to the problems identified in the history of the present illness.
source-oriented medical record
a type of patient chart record keeping that incldues seperate sections for different sources of patient information.
past medical history
includes all health problems, major illnesses, and surgeries that the patient has had.
provides clues to the patient's present condition by asking open-ended questions about medical problems of siblings, parents, and grandparents. This will alert the physician to any hereditary and familial diseases and disorders.
includes their marital status, sexual habits, occupation, hobbies, and use of alcohol, tobacco, and recreational drugs or other chemical substances.
release of information
A statement that permits the provider to give the carrier information needed to help process the claim.
protection of individuals or groups from a specific diseases by vaccination or the injection of immune globulins
required for each medication, treatment/procedure, or medical assistant action; it accounts of the patient's condition and activities must be charted in a clear and meaningful way.
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