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Bonewit Chapt#1

The medical Record(KaylonTackett

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.
Consulation 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 condition.
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 patients 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 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 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, alternative 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. Other terms for impressions include provisional diagnosis and tentative diagnosis.
Medical record A written record of important information 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 types of medical record formats are the source-oriented record and the problem-oriented record.
Objected 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 determine the patient state of health.
Physical examination report A report of the objective finding 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 patients recovery.
Reverse chronological order Arranging documents with the most recent document on top or in front, which means that the oldest document is on the bottom or at the back of a 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 observable by an examiner.
Symptom Any change in the body or its functioning that indicates the presence of disease.
Created by: kaylontackett