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Bonewit Chapter 1

The Medical Record-Arianna Butler

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