Busy. Please wait.
Log in with Clever
or

show password
Forgot Password?

Don't have an account?  Sign up 
Sign up using Clever
or

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

The Medical Record- Madison W.

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
        Help!  

Question
Answer
Attending Physician   the physician responsible for the care of a hospitalized patient  
🗑
charting   the process of making written entries about a patient in the medical record  
🗑
consultation report   a narrative report of an opinion about a patient's condition by a practitioner other than the attending physician  
🗑
diagnosis   the scientific method of determining and identifying a patient's condition  
🗑
diagnostic procedure   a procedure performed to assist in the diagnosis, management, or treatment of a patient's condition  
🗑
discharge summary report   a brief summary of the significant events of a patient's hospitalization  
🗑
electronic medical record   a medical record that is stored on a computer, abbreviated as EMR  
🗑
familial   occurring or affecting members of a family more frequently than would be expected by chance  
🗑
health history report   a collection of subjective data about a patient  
🗑
home health care   the provision of medical and non-medical care in a patient's home or place of residence  
🗑
informed consent   consent given by a patient for a medical procedure after informed of the purpose, an explanation of risks, alternative treatments or procedures available, likely outcome of the procedure, and the risks involved with declining of delaying  
🗑
inpatient   a patient who has been admitted to a hospital for at least one overnight stay  
🗑
medical impressions   conclusions drawn by the physician from an interpretation of data; other terms include provisional diagnosis and tentative diagnosis  
🗑
medical record   a written record of the important information regarding a patient, including the care of the individual and the progress of the patient's condition  
🗑
medical record format   the way a medical record is organized; the two main types of medical record formats are the source-oriented record and the problem-oriented record  
🗑
objective symptom   a symptom that can be observed by an examiner  
🗑
paper based patient record   a medical record in paper form, abbreviated as PPR  
🗑
patient   an individual receiving medical care  
🗑
physical examination   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 report   a report of the objective findings from the physician's assessment of each body system  
🗑
problem   any condition that requires further observation, diagnosis, management, or patient education  
🗑
prognosis   the probable course and outcome of a disease and the prospects for a patient's recovery  
🗑
reverse chronological order   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  
🗑
SOAP format   a method of organization for recording progress notes; includes the following categories: subjective data, objective data, assessment, and plan  
🗑
subjective symptom   a symptom that is felt by the patient, but is not observable by an examiner  
🗑
symptom   any change in the body or its functioning that indicates the presence of disease  
🗑


   

Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
 
To hide a column, click on the column name.
 
To hide the entire table, click on the "Hide All" button.
 
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
 
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.

 
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how
Created by: madisonwinget
Popular Medical sets