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bonewit

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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Question
Answer
Attending physician   Physician responsible for the care of a hospitalized patient.  
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Charting   The process of making written entires about a patient in the medical record.  
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Consultation Report   Narrative report of an opinion about patients condition by a practitioner other than the attending physician.  
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Diagnosis   The scientific method of determining and indentifying a patient's condition.  
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Diagnosis procedure   A procedure performed to assist in the diagnosis, management, or treatmeant of a patient's condition.  
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Discharged 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   Occurring 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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Informed consent   The consent given by a patients for medical procedure after being informed of the procedure.  
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Inpatient   A patients who has been admitted to the hospital for atleast one overnight stay.  
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Medical impressions   The conclusions reached by the physician from an interpretation of data.  
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Medical Records   A wriiten record of the important information regarding a patient.  
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Objective symptom   A sympton that can be observed by an examiner.  
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Patient   An individual receiving medical care.  
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Physical examination report   A report of the objective finding from the physican;s assessment of each body system.  
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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 prospect for recovery.  
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Subjective symptom   A symptom felt by the patient but not observed by an examiner.  
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Symptom   Any changes in the body or its functioning indicative that a disease is present.  
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SOAP Format   a method of organization for recording progress notes.  
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reverse chronological order   arrangingg documents with the most recent document on top or in the front  
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physical examination   an assensmentof each part of tge patients body to obtain objective data  
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Paper-based ptient record   A medical record in paper form  
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medical record format   the way a medical record is organized.  
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home health care   the provision od medical and non medical care in a patients home  
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