bonewit
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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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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