MOPS Patient Record/Medical Record Terminology MA Fall 2014
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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Correlation | To show a mutual relationship
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Diagnosis | The determination of the nature/cause of a disease
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Discernible | To see or understand a difference between two things, very clear difference
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Integral | Being an indispensable part of a whole
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Medical record | Complete set of information put down in writing to authenticate evidence of facts and events
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Medical report | A permanent legal document formally stating the results of an examination
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Objective (information) | Perceptible to the observer/external senses (i.e. Dr's conclusions)
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Observation | An inference from what has been seen or heard
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Proficiency | Competency as a result of training and experience
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Prognosis | Forecast of the outcome of a disease/injury
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Progress notes | Records of patient visits, phone calls, progress and treatment that are inserted into the patients chart
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Sign | Any objective evidence of disease discoverable by a physician on examination of a patient
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Subjective (information) | Findings perceptible only by the affected person
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Symptom | Any perceptible change in the body or its functions (indicating disease or illness)
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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.
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