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Health Records terms

Terms from Ch 2 in "Acquiring Medical Language"

TermDefinition
clinic note documents a visit
consult note provides an expert opinion on a more challenging problem
emergency department note documents an emergency department visit
admission summary documents the admission of a patient to the hospital
discharge summary describes when and why the patient was admitted; documents a longer stay
operative report documents a surgery in detail
daily hospital note/progress note documents daily hospital visit
radiology report explains reason for image, how image was performed, what was seen on image, radiologists's assessment; sometimes a recommendation
pathology report provides reasons for test, what was seen on the test, and an assessment
prescription provides directions for a medication
acute just started recently OR is a sharp, severe symptom
chronic long-term
exacerbation it is getting worse
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