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Bonewit Chapt 1
The Medical Record (Melinda Hanson)
Term | Definition |
---|---|
Attending physicians | 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 patients 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 a computer (EMR) |
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 |
Home health care | The provision of medical and nonmedical care in a patient's home or place of residents |
Informed consent | Consent given by a patient for a medical procedure after being informed of the nature of his/her condition and about the procedure, risks, alternative treatments available, outcome of procedure, risks involved in 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 include provisional diagnosis and tentative diagnosis |
Medical record | A written record of the important information regarding a patient, including the care of the individual and the progress of the 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 | A medical record in paper form, abbreviated as PPR |
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 assists 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 that the oldest document is on the bottom or at the back of a section or file |
SOAP format | A method of organization for recording progress notes; includes the following categories: subjective data, objective data, assessment, and plan |
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 |