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Bonewit Chapt 1
The Medical Record (Cheyenne Rice)
| Term | Definition |
|---|---|
| attending physician | the physician responsible for the care of a hospitalized |
| 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 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 condidion |
| discharged summary report | a brief summary of the significant events of a patients hospitalization |
| electronic medical record | a medical record that is stored on computers |
| 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 patient for a medical procedure after being informed of the nature of his/her condition, the purpose of the procedure, an explanation of risks involved with the procedure, alternative treatments or procedures available, the likely outco |
| 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 |
| 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 |
| 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 |
Created by:
cheyennerice
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