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Bonewit chapt 1

The Medical Record (Krista Elzey)

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