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Bonewit #1 (8th Ed)

The Medical Record - Mrs. Marshall

The physician responsible for the care of a hospitalized patient. Attending Physician
The process of making written entries about a patient in the medical record. Charting
A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician. Consultation report
The scientific method of determining and identifying a patient's condition. Diagnosis
A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition. Diagnostic procedure
A brief summary of the significant events of a patient's hospitalization. Discharge summary report
A medical record that is stored on a computer. Electronic medical record (EMR)
Occurring or affecting members of a family more frequently than would be expected by chance. Familial
A collection of subjective data about a patient. Health history report
The provision of medical and nonmedical care in a patient's home or place of residence. Home health care
Consent given by a patient for a medical procedure after being informed of the nature of their condition, the purpose & any risk of the procedure; alternative treatments or procedures; the likely outcome & the risk of declining or delaying the procedure. Informed consent
A patient who has been admitted to a hospital for at least one overnight stay. Inpatient
Conclusions drawn by the physician from an interpretation of data. Other terms include provisional diagnosis and tentative diagnosis. Medical impressions
A written record of the important information regarding a patient, including the care of the individual & the progress of the patient's condition. Medical record
The way a medical record is organized. The two main types are the source-oriented record & the problem-oriented record. Medical record format
A symptom that can be observed by the examiner. Objective symptom
A medical record that is paper form. Paper-based patient record (PPR)
An individual receiving medical care. Patient
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
A report of the objective findings from the physician's assessment of each body system. Physical examination report
Any condition that requires further observation, diagnosis, management, or patient education. Problem
The probable course & outcome of a disease & the prospects for a patient's recovery. Prognosis
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. Reverse chronological order
method of organization for recording progress notes & includes the following categories: subjective data, objective data, assessment & plan. SOAP format
A symptom that is felt by the patient but is not observed by the examiner. Subjective data
Any change in the body or its functioning that indicate the presence of disease. Symptom
Created by: Mrs.Marshall