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Bonewit Chap 1

The Medical Record Toritafout

Attending physcian The physcian responsible for the care of a hospitalied 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 physcian.
Diagnosis The Scientific method of determining and identifying a patients condition.
Diagnostic procedure A procedure performed to assist in the diagnosis , management, or traetment of a patients condition.
Discharge summary report A brief summary of the signifcant events of a patients hospitalization.
Electronic medical record A medical record that is stored on a computer.
Familial Occurring in or affecting memebers 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 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 gicing an explanation of risks involved with the procedure, alternative treatments
or procedures available , the likely outcome of the procedure and the risks involved with declining or delaying the procedure
Inpatient A patient who has been admitted to a hospital for atleast one overnight stay
Medical impressions Conclusions drawn by the physcian from an interpretation of data. other terms for imperssions include provisional diagnosis and tentative diagnosis
Medical record A written record of important information regrading 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.
Objective symptom A symptom that can be observed by an examiner.
Paper-based patient (PPR) A medical record in paper form
Patient 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 physican in determining the paients state of health
Physical examination report A report of the objective findings from physcians 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 the 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: toritafout