The Medical Record- Olivia Diller
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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The physician responsible for the care of a hospitalized patient | Attending Physician
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The process of making written entries about a patient in the medical record | Charting
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A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician | Consultation Report
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The scientific method of determining and identifying a patient's condition | Diagnosis
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A procedure performed to assist in the diagnosis, management or treatment of a patient's condition | Diagnostic Procedure
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A brief summary of the significant events of a patients hospitalization | Discharge summary report
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A medical record that is stored on a computer | Electronic medical record
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Occurring in or affecting members of a family more frequently than would be expected by chance | Familial
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A collection of subjective data about a patient | Health history report
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The provision of medical and nonmedical care in a patient's home or place of resident | Home health care
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Consent given by a patient for a medical procedure after he or she has been informed. | Informed consent
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A patient who has been admitted to a hospital for at least one overnight stay | Inpatient
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Conclusion drawn by the physician from an interpretation of data | Medical impressions
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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
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The way a medical record is organized. Two main types are source-oriented and problem-oriented | Medical Record format
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A symptom that can be observed by an examiner | Objective symptom
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A medical record in paper form | Paper-based patient record (PPR)
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An individual seeking medical care | Patient
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An assessment of each part of the patient's body to obtain objective data about the patient that assists the physician in determining the patient's state of health | Physical examination
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A report of the objective findings from the physician's assessment of each body system | Physical examination report
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Any condition that requires further observation, diagnosis, management, or patient education | Problem
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The probable course and outcome of a disease and the prospects for a patient's recovery | Prognosis
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Arranging documents with the most recent document on top or in front | Reverse chronological order
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A method of organization for recording progress notes. It includes the following categories: Subjective data, objective data, assessment, and plan | SOAP format
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A symptom that is felt by the patient but in not observable by an examiner | Subjective symptom
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Any change in the body or its functioning that indicates the presence of disease | Symptom
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Created by:
oliviadiller
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