Bonewit Chapt. 1 Word Scramble
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Term | Definition |
Attending Physician | The Physician responsible for the care of a hospitalized patient. |
Charting | The process of making written entries about a patient in the medical record. |
Consultation Report | A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician. |
Diagnosis | The scientific method of determining and identifying a patient's condition. |
Diagnostic Procedure | A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition. |
Discharge Summary Report | A brief summary of the significant events of a patient's hospitalization. |
Electronic Medical Record | A medical record that is stored on a computer. |
Familial | Occurring in or affecting members of a family more frequently than would be expected by chance. |
Health History Report | A collection of subjective data about patient. |
Home Health Care | The provision of medical and non-medical care in a patient home or place of residence. |
Informed Consent | Consent given by a patient for a medical procedure after he or she has been informed of the nature of his or her condition and the purpose of the procedure, and has been given an explanation of risks involved with the procedure, alternative treatments. |
Inpatient | A patient who has been admitted to a hospital for at least one overnight stay. |
Medical Impressions | Conclusions drawn by the physician from an interpretation of data. Other terms for impressions include provisional diagnosis and tentative diagnosis. |
Medical Record | A written record of important information regarding a patient, including the care of that individual and the progress of the patient's condition. |
Medical Record Format | 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. |
Objective Symptom | A symptom that can be observed by a examiner. |
Paper-based Patient Record | A medical record in paper form. |
Patient | An individual receiving medical care. |
Physical Examination | An assessment of each part of the patient's body to obtain objective data about the patient that assists the physician in determining the patient's state of health. |
Physician Examination Report | A report of the objective findings from the physician's assessment of the body system. |
Problem | Any condition that requires further observation, diagnosis, management, or patient education. |
Prognosis | The probable course and outcome of a disease and the prospects for patient's recovery. |
Reverse Chronological Order | Arrangement document with the most recent document on top or in front, which means that the oldest document is on the bottom or at the back of a section or file. |
SOAP Format | A method of organization for recording progress notes. The SOAP format includes the following categories: Subjective date, Objective data, Assessment, and Plan. |
Subjective Symptom | A symptom that is felt by the patient but is not observable by an examiner. |
Symptom | Any change in the body or its functioning that indicates the presence of disease. |
Created by:
houstondixon
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