click below
click below
Normal Size Small Size show me how
Bonewit Chapter 1
The medical record
Question | Answer |
---|---|
Attending physician | The physician responsible for the care of a hospitalized patient. |
Charting | The process of making writen entries about a patient in the medical record. |
Diagnosis | The scientific method of determining and identifying a patient's condition. |
Diagnostic procedure | A procedure performed to assist the diagnosis,management,or treatment of a patients condition. |
Discharge summary report | A breif summary of the significant events of a patient's hospitalization. |
Electronic Medical Record | A medical record that is stored on a computer. |
Familial | Occurring 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 resdience. |
Inpatient | A patient who has been admitted to a hospital for at least one over night stay. |
Medical impressions | Conclusions drawn by the physician from an interpretation of data. |
Medical record | A written record of the important information regarding a patient,including the care of that individual and the progress of the patient's condition. |
Medical record format | The way a medical record is organized.The |
Object symptom | A symptom that can be observed by an examiner. |
Paper based records | Medical record in paper form. |
Patient | an individual recieving medical care. |
Physical examination | An assesment of each part if 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 assesment 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 botttom or at the back of a section or file. |
SOAP format | A method of organization for recording progress notes. Subjective,objective,assesment,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. |
Informed consent | Consent given by a patient for a medical procedure after being informed of the nature of his or her condition,the purpose of the procedure,an explanation of the risks involved with the procedure,alternative treatments or procedure avalible,the likely |
outcome of the procedure,and the risks involved with declining or delaying the procedure. | |
suspension | |