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Bonewit Chapter 1
The Medical Record-Arianna Butler
| Question | Answer |
|---|---|
| attending physican | the physician responsible for the care of a patient while at the hospital. |
| charting | the process of making written entries about a patient in the medical record and is preformed by a medical office personnel who are directly involved with the health care of the patient. |
| consultation report | a narrative report of a clinical opinion about a patient's condition by a practitioner other than the primary physican, known as a consultant. |
| diagnosis | refers to the scientific method of determining and identifying a patient's condition. |
| diagnostic procedure | a type of 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 | electronic medical record. |
| familial | a disease that occurs in or affects blood relatives more frequently than would be expected by chance |
| health history report | a collection of subjective data about the patient. |
| home health care | the provision of medical and non medical care in a patient's home or place of residence. |
| informed consent | means that the patient has recieved the following information before giving consent. |
| inpatient | a patient who has been admitted to the hospital for at least one overnight stay. |
| medical impressions | conclusions deawn from an interpretation of data. |
| medical record | a written record of the important information regarding a patient, including the care of that individual and the progress of his or her condition. |
| medical record format | the source-oriented record and the problem-oriented record. |
| objective symptom | a symptom that can be observed by another person and by the patient. |
| PPR | a medical record in paper form |
| 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 the physician 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 | an condition that requires further observation, diagnosis, management, or patient education |
| prognosis | the probable course and outcome of a disease and the prospects for a patients 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, the SOAP format includes the following categories: subjective data, objective data, 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 a disease |
Created by:
ariannabutler
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