The Medical Record
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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| The physician responsible for the care of hospitalized patient | Attending physician
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| The process of making written entries about a patient in the medical record | Charting
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| A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician. | Consultation report
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| The scientific method of determining and identifying a patient's condition | Diagnosis
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| A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition. | Diagnostic procedure
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| A brief summary of the significant events of a patient's hospitalization. | Discharge summary report.
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| A medical record that is stored on a computer | Electronic medial record (EMR)
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| Occuring or affecting members of a family more frequently than would be expected by chance | Familial
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| A collection of subjective data about a patient | Health history report
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| The provision of medical and nonmedical care in a patient's home or place of residence | Home health care
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| Consent given by a patient for a medical procedure after being informed of the nature of his or her conditions | Informed consent
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| A patient who has been admitted to a hospital for at least one overnight stay | Inpatient
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| Conclusions drawn by the physician from an interpretation of data. | Medical impressions
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| A written record of the important information regarding a patient, including the care of that individual and the progress of the patient's condition | Medical record
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| The way a medical record organized. The two main types of medical record formats are the source-oriented record and the problem-oriented record. | Medical record format
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| A symptom that can be observed by an examiner | Objective symptom
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| A medical record in paper form | Paper based patient record (PPR)
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| An individual receiving medical care. | Patient
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| 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
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| A report of the objective findings from the physician's assessment of each body system. | Physical examination report
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| Any condition that requires further observation, diagnosis, management, or patient education. | Problem
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| The probable course and outcome of a disease and the prospects for a patient's recovery. | Prognosis
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| 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. | Reverse chronological order
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| A method of organization for recording progress notes. The SOAP format includes the following categories: subjective data, objective data, assessment, and plan | SOAP format
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| A symptom that is felt by the patient, but is not observable by an examiner | Subjective symptom
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| Any change in the body or its functioning that indicates the presence of disease | Symptom
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Created by:
ReganEntler
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