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Bonewit chapt 1
The Medical Record La'Keia Gaines
| 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 |
| consuation report | a narrative report of an opinion about a patient's condition by a practioner other than the attending physician |
| diagnosis | the scientific method of determining and identify a patient's condition |
| diagnostic procedure | a procedure performed to assist in the diagnosis, management, or treatment of a patients condition |
| discharge summary report | a brief summary of the significant events of a patients hospitalization |
| electronic medical record | a medical record that is stored on the 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 bout 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 he or she has confirmed of the nature of his or her condition and purpose |
| inpatient | a patient who has been admitted to a hospital for at least one overnight stay |
| medical impressions | medical impressions conclusions drawn by physicians |
| medical record | a written record of important information |
Created by:
lakeiagaines
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