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Bonewit Chapt 1

The Medical Record - Sierra

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