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Bonewit #1

The Medical Record- Olivia Diller

The physician responsible for the care of a hospitalized patient Attending Physician
The process of making written entries about a patient in the medical record Charting
A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician Consultation Report
The scientific method of determining and identifying a patient's condition Diagnosis
A procedure performed to assist in the diagnosis, management or treatment of a patient's condition Diagnostic Procedure
A brief summary of the significant events of a patients hospitalization Discharge summary report
A medical record that is stored on a computer Electronic medical record
Occurring in or affecting members of a family more frequently than would be expected by chance Familial
A collection of subjective data about a patient Health history report
The provision of medical and nonmedical care in a patient's home or place of resident Home health care
Consent given by a patient for a medical procedure after he or she has been informed. Informed consent
A patient who has been admitted to a hospital for at least one overnight stay Inpatient
Conclusion drawn by the physician from an interpretation of data Medical impressions
A written record of important information regarding a patient, including the care of that individual and the progress of the patient's condition Medical Record
The way a medical record is organized. Two main types are source-oriented and problem-oriented Medical Record format
A symptom that can be observed by an examiner Objective symptom
A medical record in paper form Paper-based patient record (PPR)
An individual seeking medical care Patient
An assessment of each part of the patient's body to obtain objective data about the patient that assists the physician in determining the patient's state of health Physical examination
A report of the objective findings from the physician's assessment of each body system Physical examination report
Any condition that requires further observation, diagnosis, management, or patient education Problem
The probable course and outcome of a disease and the prospects for a patient's recovery Prognosis
Arranging documents with the most recent document on top or in front Reverse chronological order
A method of organization for recording progress notes. It includes the following categories: Subjective data, objective data, assessment, and plan SOAP format
A symptom that is felt by the patient but in not observable by an examiner Subjective symptom
Any change in the body or its functioning that indicates the presence of disease Symptom
Created by: oliviadiller