Question

13. What is a SOMR? How is it organized? What is the major disadvantage of this system?" 14, What is an EMR? What are some advantages and disadvantages of this type of medical recod? 15. Define the following abbreviations: bid ac CAD BP. CVA CHF de CXR Dx DVT fx fu HTN hs MI Hx NPO NKA pt pn R/O RBC Rx stat URI VS CASE STUDIES In the following case studies, what types of interview barriers are indicated? Explain how these statements are danger- ous and may interfere with the patient interview 1. Mrs. Miller is expressing her concern about a changing mole in her left axillary region. Chris, the medical assistant obtaining her health history, makes the statement, "Mrs. Miller, the dysplastic nevus found in the left axillary region looks as if it could be malignant. You have not been using sunscreen, have you?" 2. Mr. Sunsari is being seen today for a suspicious mass in his left lung. The physician has recommended a biopsy of the mass; however, Mr. Sunsari prefers to postpone the procedure. He asks Chris what he should do about scheduling the procedure. Chris states, "I would do it right away."

Answer 1


Bans: SOMR: Source - oriented Medical Recehd (SOMR) is a type of format used for storing data in the medical record. => All reports and notes are kept in reverse chronological order in som => These are organized under the medical records formats documentation which are Cered for medical records. Disadvantages: & Discourages physicians and other team members froń reading all other main parts of chart because of dengthy 'description: * Includes aspects of all steps of nursing process

huy Ans: EMR: Electronic Medical Record : It includes all the information found in e provide's paper chart in a digital manner It includes : diagnoses, allergies, eab results, doctor's notes ele - These provides online data by prouiders for diagnosis and treatment Advantages: -> EMR is more than just paper records – It increases communication and co-ordination among team members of a healthcare -> Reduction in patient error -> Allows patierits own records to see medications : Disadvantages: -> While using EMR, looge scale of staff ' is involved => This į based on high cost material. CO ans: ac i before meals cante cibum). Bp : Blood pressure CHF i congestive Heart Failure CXR : chest x-rays DVT : Deep vein thrombosis flu : follow up Hx : history

NKA : no unown allergies pxn : paradox Network RBC : Red Blood cells Rx : A medical prescription (to take) URT : upper respiratory tract infection bid : twice a day CAD : coronary notcoy Discose CUA : Cerebrovascular accident dc i direct current ; discharge ; discontinue; Doctor of Chiropractic Dx : Diagnosis fx : Function ; Fracture HTN: Hypertension MI : Myocardial Infraction NPO: Nil per os pt : prothrombin time R/O; rule out. stat: Urgent or rush VS : vital signs, under sign.