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Bonewit #1

The Medical Record - Ayana Robinson

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'scondition.
Discharge summary report A brief summary of the significant events of a patient's hospitalization.
Electonic medical record (EMR) amedical record that isstored on a computer.
Familial Occurring in or affecting members of a family more frequently thatn would be expected by chance.
Health history report A collection of subjective data about a patient.
Home health care The povision of medical and nonmedical care in a patient's home or place of residence.
Informed consent Consent given by a patient for a medical procedure after he or she has been informed of the nauture of his or her condition and the purpose of the procedure , and has been given an ecplanation of risk involved with the procedure, alternative treatments.
Inpatient A patient who has been admited to a hospital for atleast one overnight stay.
Medical impression 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 The way a medicalrecord is organized. The two main types of medical record formats are the source-oriented record and the problem-oriented record.
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 assement 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 exmanination 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 doucuments with the most recent document on top or in front, which means that the oldest is on the bottom or at the back of a section or file.
SOAP format A method of organization of recording progress notes. The SOAP format includes the following categories: subjective data, objective data, assessment, and plan.
Subjective symptom A sysptom that is felt by the patient but is not obsevered by the examiner.
Symptom Any change in the body or its functioning that indicates the presence of disease.
Created by: ayanarobinson