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Chapter 9

Communication Human Relations

Symptom Any indication of disease or disorder that is perceived or experienced by the patient; usually described in subjective terms, for example, depressed, confused, experiencing pain, or tired
Progress report Written observations made at examinations of a patient subsequent to an initial examination
Chief Complaint The main reason why a patient is being seen in the medical office
Medical Report Permanent, legal document in letter or report format formally stating the elements performed and results of an examination and treatment of a patient
Flow-Sheet One-page lists, charts, and graphs that allow the physician to quickly find medical information and perform comparative evaluations; used for medical data that is hard to track in narrative progress notes
SOAP Abbreviation for subjective complaints, objective findings, assessment of status to obtain diagnosis and implement a treatment plan; a method of structuring progress or chart notes
Laboratory Report Clinical record of the findings of physical and chemical analysis of specimens
Medical Report Written or graphic information documenting facts and events during the rendering of patient care
Audit Periodic examination or review of patient records to verify recordkeeping, documentation for level of service billed, and proper medical care
Diagnosis Determination of the nature of a disease or injury
Ordering Physician Physician requesting non-physician services for a patient (e.g., diagnostic laboratory tests, pharmaceutical drugs, or durable medical equipment)
Case History Past and current information used in the evaluation process by the physician; part of the medical record
Prognosis Forecast of the outcome of a disease or injury
Source-Oriented Record (SOR) Common paper-based medical record management system that arranges documents according to sections
Attending Physcian Medical staff member who is legally responsible for the care and treatment given to a patient
Electronic health record (EHR) practice management system Comprehensive computerized system that manages all aspects of the health record and the medical practice (e.g., appointment scheduler, accounts receivable, accounts payable, patient billing, health insurance claim submission, patients' medical records)
Health Information Management (HIM) 1) A profession that concentrates on health care data and the management of health care information (2) department of a hospital or large clinic that stores and manages medical records; previously called medical records department (3) health care professi
Treating or performing physician Provider who renders a service to a patient or completes a test
Electronic Health Record (EHR)- Computerized medical record system that has the capability to capture and store data in electronic form and to be transmitted to other health care locations
Consulting physician Provider whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician
CHEDDAR Abbreviation for chief complaint, history, examination, details of complaints, drugs and dosage, assessment, and return visit; used as a format for charting
Referring Physician Physician sending a patient to another physician for the transfer of total or partial medical care. This term is also used loosely for a physician who sends a patient to a specialist for a consultation or for a diagnostic test
Acute Sudden onset of symptoms
Chronic Long term/ongoing symptoms or problem
Sign Indication of the presence or existence of a disease or body function disorder; objective evidence or observable physical phenomenon typically associated with a given condition
Problem-oriented medical record (POMR) Medical record keeping organizational system that contains data lists of the patients' permanent and temporary problems; each numbered and dated. Other lists are included, for example, medications, blood pressures, lab results, and surgeries.
X-ray report Written findings of an examination of a radiographic study on film
Past, Family and Social History Consists of Past history, Social history, childhood diseases/illness, family history
Created by: Tonedeoliveira