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Bonewit Chapt 1
The Medical Record - Brooklyn Burns
| 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 the patients condition by a practitioner other than the attending physician. |
| diagnosis | The scientific method of determining and identifying a patients condition. |
| diagnostic procedure | A procedure performed to assist in the diagnosis, management, or treatment of patients condition. |
| discharge summary report | A brief summary of the significant evens of a patients 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 a patient. |
| home health care | The provision of a medical and nonmedical care in a patients home or place of residence. |
| informed consent | consent given by patient for medical procedure after been informed of the condition& purpose of procedure& explanation of risks w/ procedure. Alternative treatments/ procedures available& likely outcome of procedure& risks of declining. |
| inpatient | A patient who has been admitted to a hospital for atleast one overnight stay. |
| medical impressions | Conclusions drawn by the physician from an interpretation of data. |
| medical record | A written record of important information regarding a patient, including the care and the progress of the patients condition. |
| medical record format | The way a medical |
| objective symptom | 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 physician's 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 chronological 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 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:
brooklynburns
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