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 |
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 hospitilization. | Discharge Summary Report |
A medical record that is stored on a computer. | Electronic Medical Record |
Occuring 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 being informed of the nature of his/her condition. | 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 the important information regarding a pstient, including the care of the individual and the progress of the patient's condition. | Medical Record |
The way a medical record is organized. The two main types of medical 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 recieving medical care. | Patient |
An assesment 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 |
An individual recieving medical care. | Physical Examination Report |
A medical record in paper form. | Problem |
An individual recieving medical care. | 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 a section or file. | Reverse Chronological Order |
A method of organization for recording progress notes. The SOAP format includes the following categories: subjective data, objective data, assesment, and plan. | SOAP Format |
A symptom that is felt by the patient, but is not observable by an examiner. | Subjective Symptom |
Any change in the body or its functioning that indicates the presence of disease. | Symptom |