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Bonewit chapter 1

The Medical Record- Chelsea Hawke

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.
EMR 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.
Informed consent Consent given by a patient for a medical procedure after he or she has been informed about the procedure.
Inpatient A patient who has been admitted to a hospital for at least one over night stay or 24 hours.
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 They way a medical record is organized. The two main types of medical record formats are the source-oriented and problem-oriented.
Objective symptom A symptom that can be observed by an examiner.
PPR A medical record in paper form.
Patient An individual receiving medical care.
Physical examination An assessment of each body part of the patient's body to obtain objective data about the patient that assists the physician in determining that 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 chronological order Arranging documents with the most recent in the front.
SOAP format Subjective, Objective, Assessment, 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: chelseahawke