Question | Answer |
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 patint's condition | Diagnostic procedure |
a brief summary of the significant events of a patient hospitalization | Discharge summary report |
A medical record that is stored on a computer. | Electronic medical record (EMR) |
Occurring in 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 he or she have been informed of the condition at rick of themselves. | 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. | Medical Impressions |
a written record of important information regarding a patient including the care of that individual and the progress of the patient's condition. | Medical record |
the way a medical rcord is organized. The two main types of medical record formats are the source-oriented record and the problem-oriented record. | Medical record format |
a symptom that can be observed by an examiner | Objective symptom |
a medical record in 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. | 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, mangagement, or patient education | Problem |
The probable course and outcome of a disease and the prospects for a patient's recovery | Prognosis |
arranging documents with the most recent document on top or in the front which means that the oldest document is on the bottom or at the back of the section | Reverse chronological order |
a method of organization for recordig progress notes. The SOAP format. | SOAP format |
a symptom that is felt by the patient but is not observable by an examiner | Subjective symptoms |
any change in the body or its functioning that indicates the presence of disease. | Symptom |