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Bonewit #1

Chapt 1 - Medical Record - Nora Godsey

Attending Physician The physician responsible for the care of a hospitalized patient
Charting Process of making written entries about a patient in the medical record
Consultation Report Narrative report of an opinion about a patient's condition by a practitioner other than the attending physician
Diagnosis Scientific method of determining & identifying a patient's condition
Discharge Summary Report Brief summary of the significant events of a patient's hospitalization
EMR- Electronic Medical Record 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 Provision of a medical & nonmedical care in a patients home or place of residence
Informed Consent Patient has been informed of the condition & purpose of procedure, they know the risks involved, other treatments available, outcome, & risks involved with declining or delaying procedure
Inpatient Patient who has been admitted to a hospital for at least one overnight stay
Medical Impressions Conclusions drawn by the physician form an interpretation of data. Other terms for impressions include provisional diagnosis & tentative diagnosis
Medical Record Written record of important information regarding a patient including the care of the individual & the progress of the patient's condition
Medical Record Format The way a medical record is organized; Two main types of medical record formats are the source-oriented record & the problem-oriented record
Objective Symptom Symptom that can be observed by an examiner
PPR- Paper-based Patient Record Medical record in paper form
Patient Individual receiving medical care
Physical Examination Assessment of each body to obtain objective data about the patient that assists in determining the patients health
Physical Examination Report Report of objective findings from the physicians assessment of each body system
Problem Any condition that requires further observation, diagnosis, management, or patient education
Prognosis The probable course & outcome of a disease & 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: noragodsey