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Bonewit chapt 1
The Medical Record (Krista Elzey)
| Term | Definition |
|---|---|
| attending physician | the physician responsible for the care of the hospitalized patient |
| charting | the process of making writing entries about a patient in the medical record. |
| consultation report | a narrative report of an opinion about a patients condition by a practitioner other than the attending physician |
| diagnosis | the scientific method of the determining and the identifying a patients condition |
| diagnostic procedure | a procedure preformed to assist in the diagnosis, management, or treatment of a patients condition |
| discharge summary report | a brief summary of the signifcant events of a patients hospitalization |
| Electronic medical record | a medical record that is stored on a computer |
| health history report | a collection of subjective data about a paitient |
| informed consent | a consent given by the patient after the doctor had told the patient the risks and the do's and don't oh the procedure. |
| inpatient | a patient who had been admitted to the hospital for at least one overnight stay |
| medical impression | conclusion drawn by a physician from an interpretation of data. |
| medical record | a written record regarding a patient and there history. and progress of the patients condition |
| medical record format | the way a medical record is formated. two main types source oriented and problem oriented |
| objective symptom | a symptom tat can be observed by the examiner |
| paper-based paper record | a medical record in paper form |
| patient | an individual receiving medical care |
| physical examination | an assessment of each part of the patients body to obtain objective data to help the physician determine the patients state of health |
| physical examaination report | a report of the objective findings from the physicians assessment of each body system |
| problem | any condition that requires further observations, diagnosis, management, or patients education |
| prognosis | the probable course and outcome of a disease and the prospects for a patients recovery |
| reverse chronological order | arranging document with most recent in the front and the least recent in the back |
| SOAP format | a method of organization for recording progress notes. subjective, objective, assessment, and plan |
| subjective symptoms | a symptom felt by the patient but is not observable by the examiner |
| symptom | any change in the body or its functioning the indicates the presence of disease |
| familial | occurring in or affecting members of a family more frequently than would be expected by chance |
| home health care | the provision of medical and non-medical care in a patients home or place of residence |
Created by:
kristaelzey
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