Question | Answer |
What is the word root | the fundamental meaning of the term |
What do prefixes and suffixes do? | modify the word root |
Where is the prefix added | in the front of the word |
Where is the suffix added | at the end of the word |
History and Physical | Written by admitting physician, covers history, exam results, initial diagnosis and physician's plan of treatment |
Physician's Orders | Orders from the doctor for care, medications, tests and treatments |
Nurse's Notes | Records the patient's care throughout the day, including vital signs, treatment specifics, patient's response to treatment and patient's condition |
Physician's Progress Report | Daily record of patient's condition, results from exam, summary of test results, updated assessment and diagnosis, further plans of treatment |
Consultation Reports | Exam given to a patient on the request of another physician |
Ancillary Report | From various treatments and therapies such as rehabilitation, social services, respiratory therapy or dietetics |
Operative/Surgical Report | From surgeon detailing operation includes pre and post operative diagnosis, specific details of the procedure and the patient tolerated the procedure |
Anesthesiologist's Report | Relates details of drugs given to patient, response to anesthesia and vital signs during surgery |
Diagnostic Reports | Results of all diagnostic tests performed on the patient; from lab to medical imaging |
Pathologist's Report | Report given by the pathologist who studies tissues removed from patient |
Informed Consent | Document voluntarily signed by the patient or responsible party, clearly describes purpose, methods, procedures, benefits and risks of procedure |
Discharge Report | Outline of Patient's entire hospital stay, includes condition at admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis and follow up plans |
What does HIPAA stand for? | Health Insurance Portability and Accountability Act |