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Bonwit #1

The Medical Record- Michaela Henry

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
diagnosis procedure a procedure performed to assist in the diagnosis, management, or treatment of a patient's condition
discharge summary a brief summary of the significant events of a patient's hospitalization
electronic medical record a medical record that is stored on a computer, abbreviated as EMR
familial occurring or affecting members 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 consent given by a patient for a medical procedure after being informed of the nature of his/her condition, the purpose of the procedure.
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 include provisional diagnosis and tentative diagnosis
medical report a written record of the important information regarding a patient, including the care of the individual and the progress of the patient's condition
medical report summary 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 symptoms a symptom that can be observed by an examiner
paper based patient record a medical record in paper form, abbreviated as PPR
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 in determining the patient's 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 patient's recovery
reverse order 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
SOAP format a method of organization for recording progress notes; includes the following categories: subjective data, objective data, assessment, and plan
subjective symptoms a symptom that is felt by the patient, but is not observable by an examiner
symptoms any change in the body or its functioning that indicates the presence of disease
Created by: michaelahenry