Bonewit1. Word Scramble
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Question | Answer |
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 pracitioner 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 (EMR) | A medical record that is stored on a computer. |
Familial | Occurring or affecting memers of a family more frequently than would be expected by chance. |
Health History Report | A collection of subjective data about a patient. |
Home Health Care | The provision of medical and non-medical care in a patient's home or place of residence. |
Informed Consent | The consent given by a patient for a medical procedure after being informed of the procedure. |
Inpatient | A patient who has been admitted to a hospitial for at least one overnight stay. |
Medical Impressions | Conclusions drawn by the physician from interprettion of data. |
Medical Record | A written record of the important information regarding a patient. |
Medical Record Format | The way a medical record is organized. |
Objective Symptom | A symptom that can be observed by an examiner. |
Paper-Based Patient Record (PPR) | A medical Record in paper form. |
Patient | An individual receiving medical care. |
Physical Examination | An assessment of each part of the patients body to obtain objective data about the patient that assists determining the patients state of health. |
Physical Examination Report | A report of the objective findings from the physicians assessment of each 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 a patients recovery. |
Reverse Chronological Order | Arranging documents with the most recent document on the top or in the front, which that means the oldest document is on the bottom or at the back of a section. |
SOAP Format | A method of organization for recording progress notes. |
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:
brittanycaupp
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