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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 |