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Bonewit Chapt 1
The Medical Record (Kali Dansingburg)
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 indentifying about a patient's condition. |
Diagnosis 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. |
Familial | Occurring in or affecting members of a family more frequently than would be expected by a chance. |
Health history report | A collection of subjective data about a patient. |
Home health care | The provision of medical and nonmedical care in a patient's home or place of residence. |
Informed consent | Consent given by a patient for a medical procedure after he or she has been informed of the nature of his or her condition; the likely outcome of the procedure, and the risks involved with the declining or delaying the procedure. |
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. |
Medical Record | A written record of important information regarding a patient, including the care of that individual and the progress of the patient's care. |
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. |
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 the physician 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. |
Reserve 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. The SOAP format 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. |