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.
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| The physician responsible for the care of a hospitalizd 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 patients condition by a practioner other than the attenting physician | consultation report
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| the scientific method of determining and identifying a patients condition | diagnosis
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| a procedure performed to assist in the diagnosis, management, or treatment of a patients condition. | diagnostic procedure
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| a brief summary of the significant events of a patients hospitalization | discharge summary
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| a medical record that is stored on a computer | electronic medical record (EMR)
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| occuring or affecting members of a family more frequently then 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 prousion of medical and non-medical care in a patients 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 the condition,the purpose of the procedure,and explanation of risk involved,other treatment or procedure available,the prognosis,and the risk involved in declining it | 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 infromation regarding a patient including the care of that individual and the progress of the patients condition | medical record
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| the way a medical record is organized. The two main types of medical record format 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 patients body to obtain objective data about the patient taht assists in determining the patients 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 patiend education. | problem
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| the probable course and outcome of a disease and the prospects for a patients 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 botton 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 formant includes the following catefories: subjective data, objective data, assessment, and plan | SOAP format
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| a symptom that is flet 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:
AlyssaSearls
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