Chapter 1 bonwit
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 physicain responsibke for the care of the 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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| the scientific method of determining and indentifying a patients condition | diagnosis
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| a narrative report of an opinion about a patients condition by a pracitioner other than the attending physician | consultation report
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| a procedure performed to assist in the diagnosis management or treatment ot a patients condition | diagnostic procedure
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| a brief summary of the significant events of a patients hospotalization | discharge summary report
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| a medical record that is stored on a computer | EMR - electronic medical record
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| occurruing or affecting members of subjective memebers 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 patients home or place of redience | home health care
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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 physicain from an interpretation of data | medical impression
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| a written record of the importance information regarding a patient, including the care of the indicidual 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 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 a examiner | objective symptom
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| an assessment of each part of the patients body to obtain objective data about the patient that assists in the determining the patients state of health | physical examination
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| a report of the objective findings from the physicains 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 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 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: subjetive, objective, assessment, 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 indicated the presence of disease | symptom
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| consent given by a patient for a medical procedure after being informed of the nature of his or her condition. the purpose of the procedure alternative treatment or procedures available the likely out come of the | informed consent
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| a medical record in paper form | PPR
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| individual receiving medical care | patient
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Created by:
Breanneharber
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