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chapter 1

chapter 1 review

QuestionAnswer
What is the word root the fundamental meaning of the term
What do prefixes and suffixes do? modify the word root
Where is the prefix added in the front of the word
Where is the suffix added at the end of the word
History and Physical Written by admitting physician, covers history, exam results, initial diagnosis and physician's plan of treatment
Physician's Orders Orders from the doctor for care, medications, tests and treatments
Nurse's Notes Records the patient's care throughout the day, including vital signs, treatment specifics, patient's response to treatment and patient's condition
Physician's Progress Report Daily record of patient's condition, results from exam, summary of test results, updated assessment and diagnosis, further plans of treatment
Consultation Reports Exam given to a patient on the request of another physician
Ancillary Report From various treatments and therapies such as rehabilitation, social services, respiratory therapy or dietetics
Operative/Surgical Report From surgeon detailing operation includes pre and post operative diagnosis, specific details of the procedure and the patient tolerated the procedure
Anesthesiologist's Report Relates details of drugs given to patient, response to anesthesia and vital signs during surgery
Diagnostic Reports Results of all diagnostic tests performed on the patient; from lab to medical imaging
Pathologist's Report Report given by the pathologist who studies tissues removed from patient
Informed Consent Document voluntarily signed by the patient or responsible party, clearly describes purpose, methods, procedures, benefits and risks of procedure
Discharge Report Outline of Patient's entire hospital stay, includes condition at admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis and follow up plans
What does HIPAA stand for? Health Insurance Portability and Accountability Act
Created by: dfargo
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