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Bonewit #1

The Medical Record- Shelby

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 or an opinion about a patient's condition by a practitioner other that the attending physician
Diagnosis The scientific method of determining and identifying a patients condition
Diagnostic Procedure A procedure preformed at assist in the diagnosis, management, or treatment of a patient's condition
Discharge Summary Report A brief summery of the significant events of a patient's 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 provision of medical and nonmedical care in a patient's home or place of residence
Informed Consent Consent giving by a patient for a medical procedure after he or she has be informed for the nature of there condition and the purpose of the procedure ect.
Inpatient A patient who has been admitted to a hospital for at least one overnight stay
Medical Impressions Conclusions drawn by the phydician from an interpretation of data. Other terms for impressions include provisional diagnosis and tentative diagnosis
Medical Records A written record of important information regarding a patient a patient, including the care of that individual and the progress of the patient's condition
Medical Record format The way a medical redord is organized. The two main types of medical record formats are the source-oriented record and the problem- oriented record
Objective symptom A symptom that can be observed by an examiner
Paper-based patient record a medical record in paper form
Pateint an individual receving medical care
Physical examination an assessment of each part of the patients body to obtain objective data about the patient that assists the physician in determining the patients state of health
Physical Examination report a report of the objective findings fron the physician's assessment of each body system
Problem sny condidtion that requires further observation, diagnosis or patients
Prognosis THe probable course and outcome of a disease and the prospects of a patients recovery
REverse chronological order Arranging documents witht the ost recent document on top of in the front. which means that te oldest document is on the bottom or in the back of the section or file.
SOAP format A method of organization for recording progress notes. The SOAP formant included the following categories: subjective, objective, assessment, and plan
Subjective Symptom a symptom that is felt by the patient but is not observable by an examiner
Symptom Any change in the body of it's functioning that indicates the presence of disease.
Created by: shelbycrank