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Chapter 1


Attending physician Physician responsible for the care of a hospitalized patient.
Charting The process of making written entires about a patient in the medical record.
Consultation Report Narrative report of an opinion about patients condition by a practitioner other than the attending physician.
Diagnosis The scientific method of determining and indentifying a patient's condition.
Diagnosis procedure A procedure performed to assist in the diagnosis, management, or treatmeant of a patient's condition.
Discharged summary report A brief summary of the significant events of a patients 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.
Informed consent The consent given by a patients for medical procedure after being informed of the procedure.
Inpatient A patients who has been admitted to the hospital for atleast one overnight stay.
Medical impressions The conclusions reached by the physician from an interpretation of data.
Medical Records A wriiten record of the important information regarding a patient.
Objective symptom A sympton that can be observed by an examiner.
Patient An individual receiving medical care.
Physical examination report A report of the objective finding from the physican;s assessment 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 prospect for recovery.
Subjective symptom A symptom felt by the patient but not observed by an examiner.
Symptom Any changes in the body or its functioning indicative that a disease is present.
SOAP Format a method of organization for recording progress notes.
reverse chronological order arrangingg documents with the most recent document on top or in the front
physical examination an assensmentof each part of tge patients body to obtain objective data
Paper-based ptient record A medical record in paper form
medical record format the way a medical record is organized.
home health care the provision od medical and non medical care in a patients home
Created by: heathertaylor