The Medical Record - Sierra
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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 patients condition by a practitioner other than the attending physician.
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| Diagnosis | The scientific method of determining and identifying in a patients condition.
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| Diagnostic procedure | A procedure performed to assist in the diagnosis, management, or treatment of a patients condition.
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| Discharge summary report | A brief summary of the significant events of a patients hospitalization.
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| Electronic medical record | A medical record that is stored on a computer.
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| Familial | Occuring 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 patients 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 nature of his or her condition and the purpose of the procedure.
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| Impatient | A patient who has been admitted to a hospital for atleast one overnight stay.
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| Medical impressions | Conclusions drawn by the physician from an interpretation of data.
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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.
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| Medical record format | The way a medical record is organized.
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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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| Patient | An individual receiving 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.
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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 patients recovery.
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| Reverse chronological order | Arranging documents with the most recent document on the top or in front.
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| SOAP format | A method of organization for recording progress notes.. Subjective data, Objective data, Assessment, and Plan.
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| Subjective Symptom | A symptom that is felt by the patient but can not be observed.
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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:
sierrawaugh
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