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Bonewit chpt 1

The Medical Records- Candace Oty

Attending physician The physician responsible for the care of a hospitalized patient.
Charting The process of making written entries about a patient in the medical record.
Consultation report A narrative report of an opinion about a patients condition by a practitioner other than the attending physician
Diagnosis The scientific method of determining and identifying a patients condition.
Diagnostic procedure A procedure performed to assist in the diagnosis,management, or treatment of a patients condition.
Discharge summary record A brief summary of the significant events of a patients hospitalization.
Electrical medical record(EMR) A medical record that is stored on a computer.
Familial Occurring in or affecting members of a family more frequently than would be expected by chance.
Health history report A collection of subjective data about a patient.
Home health care The provision of medical and non-medical care in a patients home or place of residence
Informed consent Consent given by a patient for a medical procedure after he or she has been informed of the nature of his or her condition and the purpose of the procedure,and has been given an explanation of risks involved with the procedure
Inpatient A patient who has been admitted to a hospital for at least one overnight stay
Medical impressions Conclusions drawn by the physician from interpretation of data.Other terms for impressions include provisional diagnosis and tentative diagnosis
Medical record A witten record of important regarding a patient, including the care of that individual and the progress of the patients condition.
Medical record format The way a medical record is organized. The two main typs of medical record formats are the source-oriented record and the problem-oriented record
Objective symptoms A symptom that can be observed by an examiner.
Paper based patient records(PPR) A medical record in paper form.
Patient An individual receiving medical care.
Physical examination An assessment of each part of the patients body to obtain objective data about a patient that assists the physician in determining the patients state of health
Physical examination report A report of the objective finding from the physicians assessment of each body system
Problem Any condition that requires further observation diagnosis management, or patient education.
Prognosis The probably course and outcome of a disease and the prospects for a patients recovery.
Reverse Chronology call order Arranging documents with the most recent document on top or in the front, which means that the oldest document is on the bottom on at back of a section or file.
SOAP format A method of organization for recording progress notes. The SOAP format includes the following categories:
Subjective symptom A symptom that is felt by the patients but is not observable by an examiner.
Symptoms Any change in the body or its functioning that indicates the presences of disease
Created by: candaceoty