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Bonewit Chapter 1
The Medical Record - Brooklynn Crowe
Term | Definition |
---|---|
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 | the scientific method of determining and identifying a patient's condition |
diagnostic procedure | a 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 |
electronic medical record | a medical record that is stored on a computer, abbreviated as EMR |
familial | occurring 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 non-medical care in a patient's home or place of residence |
informed consent | consent given by a pt for a medical procedure after being infod of the nature of his/her condit, the purpose of the proce,an explanation of risks involved with the proce, alternative treatments or procedures available, the chance proce,&the risks involved |
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 |
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 |
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 |