The Medical Record - Ayana Robinson
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| Attending physician | The physician responsible for the care of a hospitalized patient.
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| Charting | The process of making written entries about a patient in the medical record.
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| Consultation report | A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician.
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| Diagnosis | The scientific method of determining and identifying a patient's condition.
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| Diagnostic procedure | A procedure performed to assist in the diagnosis, management, or treatment of a patient'scondition.
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| Discharge summary report | A brief summary of the significant events of a patient's hospitalization.
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| Electonic medical record (EMR) | amedical record that isstored on a computer.
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| Familial | Occurring in or affecting members of a family more frequently thatn would be expected by chance.
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| Health history report | A collection of subjective data about a patient.
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| Home health care | The povision of medical and nonmedical care in a patient's home or place of residence.
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| Informed consent | Consent given by a patient for a medical procedure after he or she has been informed of the nauture of his or her condition and the purpose of the procedure , and has been given an ecplanation of risk involved with the procedure, alternative treatments.
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| Inpatient | A patient who has been admited to a hospital for atleast one overnight stay.
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| Medical impression | Conclusions drawn by the physician from an interpretation of data. Other terms for impressions include provisional diagnosis and tentative diagnosis.
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| Medical record | A written record of important information regarding a patient, including the care of that individual and the progress of the patient's condition.
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| Medical record format | The way a medicalrecord is organized. The two main types of medical record formats are the source-oriented record and the problem-oriented record.
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| Objective symptom | A symptom that can be observed by an examiner.
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| Paper-based patient record (PPR) | A medical record in paper form.
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| Patient | An individual receiving medical care.
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| Physical examination | An assement 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.
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| Physical exmanination report | A report of the objective findings from the physician's assessment of each body system.
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| Problem | Any condition that requires further observation, diagnosis, management, or patient education.
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| Prognosis | The probable course and outcome of a disease and the prospects for a patient's recovery.
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| Reverse chronological order | Arranging doucuments with the most recent document on top or in front, which means that the oldest is on the bottom or at the back of a section or file.
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| SOAP format | A method of organization of recording progress notes. The SOAP format includes the following categories: subjective data, objective data, assessment, and plan.
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| Subjective symptom | A sysptom that is felt by the patient but is not obsevered by the examiner.
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| Symptom | Any change in the body or its functioning that indicates the presence of disease.
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Created by:
ayanarobinson
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