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Bonewit #1
The Medical Record- Olivia Diller
| Question | Answer |
|---|---|
| The physician responsible for the care of a hospitalized patient | Attending Physician |
| The process of making written entries about a patient in the medical record | Charting |
| A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician | Consultation Report |
| The scientific method of determining and identifying a patient's condition | Diagnosis |
| A procedure performed to assist in the diagnosis, management or treatment of a patient's condition | Diagnostic Procedure |
| A brief summary of the significant events of a patients hospitalization | Discharge summary report |
| A medical record that is stored on a computer | Electronic medical record |
| Occurring in or affecting members of a family more frequently than would be expected by chance | Familial |
| A collection of subjective data about a patient | Health history report |
| The provision of medical and nonmedical care in a patient's home or place of resident | Home health care |
| Consent given by a patient for a medical procedure after he or she has been informed. | Informed consent |
| A patient who has been admitted to a hospital for at least one overnight stay | Inpatient |
| Conclusion drawn by the physician from an interpretation of data | Medical impressions |
| 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 |
| The way a medical record is organized. Two main types are source-oriented and problem-oriented | Medical Record format |
| A symptom that can be observed by an examiner | Objective symptom |
| A medical record in paper form | Paper-based patient record (PPR) |
| An individual seeking medical care | Patient |
| 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 | Physical examination |
| A report of the objective findings from the physician's assessment of each body system | Physical examination report |
| Any condition that requires further observation, diagnosis, management, or patient education | Problem |
| The probable course and outcome of a disease and the prospects for a patient's recovery | Prognosis |
| Arranging documents with the most recent document on top or in front | Reverse chronological order |
| A method of organization for recording progress notes. It includes the following categories: Subjective data, objective data, assessment, and plan | SOAP format |
| A symptom that is felt by the patient but in not observable by an examiner | Subjective symptom |
| Any change in the body or its functioning that indicates the presence of disease | Symptom |
Created by:
oliviadiller
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