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Bonewit chapt 1

The Medical Record La'Keia Gaines

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
consuation report a narrative report of an opinion about a patient's condition by a practioner other than the attending physician
diagnosis the scientific method of determining and identify a patient's 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 the 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 bout a patient
home health 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 he or she has confirmed of the nature of his or her condition and purpose
inpatient a patient who has been admitted to a hospital for at least one overnight stay
medical impressions medical impressions conclusions drawn by physicians
medical record a written record of important information
Created by: lakeiagaines