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Bonewit Chapt 1

The Medical Record (Melinda Hanson)

Attending physicians 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 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 patients 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 a computer (EMR)
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 residents
Informed consent Consent given by a patient for a medical procedure after being informed of the nature of his/her condition and about the procedure, risks, alternative treatments available, outcome of procedure, risks involved in declining or delaying the procedure
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 include provisional diagnosis and tentative diagnosis
Medical record A written record of the important information regarding a patient, including the care of the 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 A medical record in paper form, abbreviated as PPR
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 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 a section or file
SOAP format A method of organization for recording progress notes; 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: melindahanson