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Bonewit Chapt 1

The Medical Record - Karly Hayes

the process of making written entries about a patient in the medical record charting
a narrative report of an opinion about a patients condition by practitioner other than the attending physician consultation report
the scientific method of determining and identifying a patients condition diagnosis
a procedure performed to assist in the diagnosis, management, or treatment of a patient condition diagnostic procedure
a brief summary of the significant events of a patients hospitalization discharge summary report
a medical record that is stored on a computer electronic medical record
occuring in or addecting memebers of a family more frequently than would be expected by chance familial
a collection of subjective data about a patient health history report
the provision of medical and nonmedical care in a patients home or placec of residence home health care
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, and has been given an explanation of risks involved with the procedure, alternative treatments informed consent
a patient who has been admitted to hospital for at least one overnight stay inpatient
conclusions drawn by the physician from an interpretation of data medical impressions
a written record of important information regarding a patient, including the care of that individual and the process of the patients condition medical record
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 medical record format
a symptom that can be observed by an examiner objective symptom
a medical record in paper form pater-based patient record
an individual receiving medical care patient
an assessment of each part of the patients body to obtain objective date about the patient that assists the physician in determining the patients state of health physical examination
a report of the objective findings from the physicians assessment of each body system physical examination report
any condition that requires further observation, diagnosis, management, or patient education problem
the probable course and outcome of a disease and the prospects for a patients recovery prognosis
arranging documents with the most recent documents on top or in the front, which means that the oldest documents is on te bottom or at the back of a section or file reverse chronological order
a method of organization for recording progress notes. the SOAP format includes the following categories: subjective data, objective data, assessment, and plan SOAP format
a symptom that is felt by the patient but is not observable by an examiner subjective symptoms
any change in the body or its functioning that indicated the presence of diseases symptoms
Created by: karlyhayes