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Bonewit #1
The Medical Record - Ayana Robinson
| 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 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
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