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Bonewit # 1

The Medical Record - emily lawson

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 particular 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 report a brief summary of the significant events of a patients hospitalization.
electronic medical record 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 procision of medical and non medical care in a paitients home or place of residence.
informed consent consent given by a paitient for a medical procedure after he or she has neem informed of the nature of his or her condition and the purpose of the procedure and has been given an explanation of risks inolved with the procedure altrenative treatments.
inpatient a patient who has been admitted to a hospital for at least one overnight stay.
medical impressions conclusions drawn by the physician from an interpretation of data
medical record a written record of important information of a paitent
medical record format the way a medical record is organized the two main types of medical record formats are the source-oriented
objective symptom a symptom that can be observed by an examiner
paper based patient record a medical record in patient form
physical examination an assessment of each part of the patients body to obtain objective data about the patient that assist the physician in determining the patients state of health.
physical examination report a report of the objective findings from the physicians assessment of each body system
problem any condition that requires further observation, diagnosis, management, or patient education
prognosis the probable course and outcome of a disease and the prospects for a patients recovery
reverse chronilogical order arranging documents with the most recent document on top or in the front, which means that the oldest document is on the bottom or at the back section or file
SOAP format a method of organization for recording progress notes. the SOAP format includes the following categories: subjective data, objective data, assessment, plan.
subjective symptom a symptom that is felt by the patient but is not observable by the examiner.
symptom any change in the body or its functioning that indicates the presence of disease.
Created by: emilylawson