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Bonewit Chapter 1

The Medical Record

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 electronical 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 non-medical 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 his/her condition, the purpose of the procedure, explanations of the risks involved, alternative treatments available the likely outcome informed consent
a patient who has been admitted to the hospital for at least one over night stay inpatient
a written record of the important info regarding a patient, including the care of that individual and the progress of the patient's condition medical record
the way a medical record is organized. the two main two main types of medical record formats are the source oriented and the problem oriented record medical record format
a symptom that can be observed by an examiner objective symptom
a medical record in paper format 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 physicians assessment of each body system physical examination report
any condition that requires further observation, diagnosis, management, or patient education problem
the probable course and outcome of a disease ans the prospects for a patient's recovery prognosis
arranging documents with the most recent document on top and the oldest document in the back or the bottom of the file reverse chronological order
a method of organization for recording progress notes. Categories: Subjective, Objective, Assessment, Plan SOAP format
a symptom that is felt by the patient, but is not observable by the examiner subjective symptom
any change in the body or its functioning that indicates the presence of a disease symptom
conclusions drawn by the physician from interpretation of data medical impressions