Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Bonewit Chapter 1
The Medical Record- Hannah McCall
| 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 | Scientific method of determining and identifying a patient`s condition |
| Diagnostic Procedure | Procedure performed to assist in the diagnosis, management, or treatment of a patient`s condition |
| Discharge Summary Report | Brief summary of the significant events of a patient`s hospitalization |
| Electronic Medical Record (EMR) | 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 | Collection of subjective data about a patient |
| Home Health Care | The provision 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/she has been informed of the nature of his/her condition and the purpose of the procedure |
| inpatient | a patient who has been admitted to a hospital for at least one overnight stay |
| medical impressions | conclusions drawn by the physician from an interpretation of data; other terms include provisional diagnosis and tentative diagnosis |
| medical record | a written record of the important information regarding a patient, including the care of the individual and the progress of the patient's condition |
| medical record format | the way a medical record 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 | a medical record in paper form, abbreviated as PPR |
| 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 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 | 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 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; includes the following categories: subjective data, objective data, assessment, and 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:
hannahmccall
Popular Medical sets