The Medical Record- Shelby
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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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 or an opinion about a patient's condition by a practitioner other that the attending physician
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| Diagnosis | The scientific method of determining and identifying a patients condition
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| Diagnostic Procedure | A procedure preformed at assist in the diagnosis, management, or treatment of a patient's condition
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| Discharge Summary Report | A brief summery of the significant events of a patient's hospitalization.
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| Electronic Medical Record | A medical Record that is stored on a computer
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| Familial | Occurring in or affecting members of a family more frequently than 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 provision of medical and nonmedical care in a patient's home or place of residence
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| Informed Consent | Consent giving by a patient for a medical procedure after he or she has be informed for the nature of there condition and the purpose of the procedure ect.
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| Inpatient | A patient who has been admitted to a hospital for at least one overnight stay
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| Medical Impressions | Conclusions drawn by the phydician from an interpretation of data. Other terms for impressions include provisional diagnosis and tentative diagnosis
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| Medical Records | A written record of important information regarding a patient 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 medical redord 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 | a medical record in paper form
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| Pateint | an individual receving medical care
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| Physical examination | an assessment of each part of the patients body to obtain objective data about the patient that assists the physician in determining the patients state of health
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| Physical Examination report | a report of the objective findings fron the physician's assessment of each body system
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| Problem | sny condidtion that requires further observation, diagnosis or patients
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| Prognosis | THe probable course and outcome of a disease and the prospects of a patients recovery
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| REverse chronological order | Arranging documents witht the ost recent document on top of in the front. which means that te oldest document is on the bottom or in the back of the section or file.
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| SOAP format | A method of organization for recording progress notes. The SOAP formant included the following categories: subjective, objective, assessment, and plan
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| Subjective Symptom | a symptom that is felt by the patient but is not observable by an examiner
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| Symptom | Any change in the body of it's functioning that indicates the presence of disease.
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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.
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Created by:
shelbycrank
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