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Bonewit #1
Chapt 1 - Medical Record - Nora Godsey
Question | Answer |
---|---|
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 |