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Bonewit chapter 1

The medical record

Attending physician the physician resondible for the care of a hospitalized patient
Charting the process of making written entries baout a patient in the medical record
Consultation report a narritive 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 patient's comdition
Diagnostic procedure a procedure performed to assist in the diagnosis,management,ot treatment of a patient's condition
Discharge summary report a brief summary of the significant events of a patient's hospitalization
Electronic medical record a medical record that is stored on a computer
Familial occuring 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 non-medical care in a patient's home or place of residence
Informed concent the concent given by a pateint for medical procedure after being informed of the procedure
Inpatient a patient who has been admitted to the hospitlal fot at least one overnight stay
Medical impressions the conclusions reached by a physician from an inturpritation of data
Medical record a written record of the important information regaurding a patient
Medical record format the way in wich a medical record is organized. the two main ways are:source-oriented and problem-oriented
Objective symptom a symptom that can not be observed by examiner
Patient an individual receiving medical care
Paper-based patient record (PPR) a medical record on paper
physical examination assesment of each part of the patient's body to obtain objective data
physical examination report a report of the objective findings from the physician's assesment of each body system
Problem any condition that requires futher observations,diagnosis,management,or patient education
Prognosis the probable course and outcome of a disease and the prospect for recovery
Reverse chronological order arrainging documents with the most recent document on top or in front
SOAP format organization of recording notes;S-subjective data,O-objective data,A-assesment,and P-plan
Subjective symptom a symptom felt by the patient but not observed by an examiner
Symptom any changr in the body or its functioning indicative that a disease is present
Created by: AnnaJoseph