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Bonewit Chapt 1

The Medical Record (Allysa Jasper)

Attending physician The physician responsible for the care of a hospitalized patient
Charting The process of making entries about a patient in the medical record
Consultation report A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician
Diagnosis The scientific method of determining and identifying a patient's conditon
Diagnostic procedure A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition
Discharge summary report A brief summary of the significant events of a patient's hospitalization
Electronic medical record (EMR) A medical record that is stored on a computer
Familial Occurring in or affecting members of a family more frequently then would be expected by chance
Health history report A collection of subjective data about a patient
Health home care The provision of medical and non medical care in a patient's home or place of residence
Informed consent consent given by a patient for a medical procedure after being informed of the nature of his/her condition, the purpose of the procedure, an explanation of risks involved with the procedure, alternative treatments or procedures available, the likely outco
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 regrading a patient, including the care of that individual and the progress of the patient's condition
Medical record format The way a medical record 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 (PPR) A medical record in paper form
Patient An individual receiving medical care
Physical examination 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 report A report of the objective findings from the physician's 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 patient's recovery
Reverse chronological 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 of 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, and plan
Subjective symptom A symptom that is felt by the patient but is not observing by an examiner
Symptom Any change in the body or its functioning that indicates the presence of disease
Created by: allysajasper