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 patient's condition | diagnostic procedure |
a brief summary of the significant events of a patient's hospitalization | discharge summary report |
a medical record that is stored on a computer | electronical medical record(EMR) |
occurring 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 non-medical 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, the purpose of the procedure, explanations of the risks involved, alternative treatments available the likely outcome | informed consent |
a patient who has been admitted to the hospital for at least one over night stay | inpatient |
a written record of the important info regarding a patient, including the care of that individual and the progress of the patient's condition | medical record |
the way a medical record is organized. the two main two main types of medical record formats are the source oriented and the problem oriented record | medical record format |
a symptom that can be observed by an examiner | objective symptom |
a medical record in paper format | 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 that assists in determining the patient's state of health | physical examination |
a report of the objective findings from the physicians assessment of each body system | physical examination report |
any condition that requires further observation, diagnosis, management, or patient education | problem |
the probable course and outcome of a disease ans the prospects for a patient's recovery | prognosis |
arranging documents with the most recent document on top and the oldest document in the back or the bottom of the file | reverse chronological order |
a method of organization for recording progress notes. Categories: Subjective, Objective, Assessment, Plan | SOAP format |
a symptom that is felt by the patient, but is not observable by the examiner | subjective symptom |
any change in the body or its functioning that indicates the presence of a disease | symptom |
conclusions drawn by the physician from interpretation of data | medical impressions |