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Bonewit Chapt 1
The Medical Record Logan Greene
| 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 | (EMR) 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 chance. |
| Health History Report | A collection of subjective data about a patient. |
| Informed Consent | Consent given by a patient for a medical procedure after he/she has been informed of the nature of his/her condition and the required information including the 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. Other terms for impressions include provisional diagnosis and tentative diagnosis. |
| Medical Record | A written record of important information regarding a patient, including the care of that individual and the progress of that 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 | (PPR)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 assist 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 |
| Reverse Chronological Order | Arranging documents with the most recent document on top or in the front, which means the oldest document is on the bottom or at the back of a section or file. |
| 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. |
| Home Health Care | The provision of medical and nonmedical care in a patient's home or place of residence. |
Created by:
logangreene
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