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Bonewit Chapt 1
The Medical Record - Sierra
| 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 patients condition by a practitioner other than the attending physician. |
| Diagnosis | The scientific method of determining and identifying in a patients condition. |
| Diagnostic procedure | A procedure performed to assist in the diagnosis, management, or treatment of a patients condition. |
| Discharge summary report | A brief summary of the significant events of a patients hospitalization. |
| Electronic medical record | A medical record that is stored on a computer. |
| Familial | Occuring in or affecting members of a family more frequently than would be expected by chance. |
| Health history report | A collection of subjective data about a patient. |
| Home health care | The provision of medical and nonmedical care in a patients 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 nature of his or her condition and the purpose of the procedure. |
| Impatient | A patient who has been admitted to a hospital for atleast one overnight stay. |
| Medical impressions | Conclusions drawn by the physician from an interpretation of data. |
| Medical record | A written record of important information regarding a patient, including the care of that individual and the progress of the patient. |
| Medical record format | The way a medical record is organized. |
| Objective symptom | A symptom that can be observed by an examiner. |
| Paper-based patient record | A medical record in paper form. |
| Patient | An individual receiving medical care. |
| Physical examination | An assessment of each part of the patients body to obtain objective data about the patient that assists the physician. |
| 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 patients recovery. |
| Reverse chronological order | Arranging documents with the most recent document on the top or in front. |
| SOAP format | A method of organization for recording progress notes.. Subjective data, Objective data, Assessment, and Plan. |
| Subjective Symptom | A symptom that is felt by the patient but can not be observed. |
| Symptom | Any change in the body or its functioning that indicates the presence of disease. |
Created by:
sierrawaugh
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