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 a 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 | electronical medical record(EMR)
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| occurring 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 non-medical 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/her condition, the purpose of the procedure, explanations of the risks involved, alternative treatments available the likely outcome | informed consent
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| a patient who has been admitted to the hospital for at least one over night stay | inpatient
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| a written record of the important info 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 is organized. the two main two main types of medical record formats are the source oriented 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 format | 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 physicians 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 ans the prospects for a patient's recovery | prognosis
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| arranging documents with the most recent document on top and the oldest document in the back or the bottom of the file | reverse chronological order
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| a method of organization for recording progress notes. Categories: Subjective, Objective, Assessment, Plan | SOAP format
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| a symptom that is felt by the patient, but is not observable by the examiner | subjective symptom
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| any change in the body or its functioning that indicates the presence of a disease | symptom
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| conclusions drawn by the physician from interpretation of data | medical impressions
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Created by:
CorabethCarpenter
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