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MOPS

Patient Record/Medical Record Terminology

TermDefinition
Correlation To show a mutual relationship
Diagnosis (Dx) The determination of the natural/cause of a disease
Discernible To see or understand a difference between two things, very clear difference
Integral Being an indispensable part of a whole
Medical record Complete set of information put down in writing to authenticate evidence of facts and events
Medical report A permanent legal document formally stating the results of an examination
Objective (information) Perceptible to the observer/external senses (i.e. Dr's conclusions)
Observation An inference from what has been seen or heard
Proficiency Competency as a result of training & experience
Prognosis Forecast of the outcome of a disease/injury
Progress notes Records of patient visits, phone calls, progress & treatment that are inserted into the patients chart
Sign Any objective evidence of disease discoverable by a physician on examination of a patient
Subjective (information) Findings perceptible only by the affected person
Sympton Any perceptible change in the body or its functions (indicating disease or illness).
Created by: wenchie040
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