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Terms and Patient Record

What is the diference between medical record and medical report. Report - One sheet stating result of exam. Record - complete set of patient information.
Determination of a disease Diagnosis
The study of the causes of a disease. Etiology
Forcast of the outcome of a illness. Prognosis
A sign is what kind of information objective
A symptom is what kind of information Subjective
What does SOAP stand for? Subjective, Objective, Assessment and Plan
What do you do first to correct an error? Put a single through the mistake
What do you do second to correct an error? Write 'error' above mistake
What do you do third to correct an error? Near error you write the date including the year and your intitnals.
What is the last step to correcting a mistake? Write the correct information
List three benefits of shingling 1 - saves space 2 - Prevents loss of records 3- allows for the most recent report to be readily available
Te SOAP approach of writing progress notes is known as what method of record keeping Traditional
How should reports be placed in a patient's chart Reverse chronogical order
First item medical records are used for Patient education
Second item medical records are used for Research
Third item medical records are used for Evaluate
What does congenital mean Birth defect
Are congenital defects subjective or objective They can be both
What is a pocket Call Record Doctor carries to out of office visit
Is the condition of a patient at the time of termination of treatment objective or subjective objective
Should a doctor chart the condition of a patient when treatment is terminated Yes
What should happen before any transcribed notes or lab reports are placed in patients medical record? Doctor should intitial
What does POMR stand for Problem Oriented Medical Record
Define percussion Tapping done with fingers for sounds
Define inspection Exam with eyes
Define Palpation Exam by feeling
Define Auscultation Listening to sounds with stethoscope
Is there a different in how you correct handwritten or typewritten errors No
To show a mutual relationship correlation
Determation of the nature / cause of a disease Diagnosis
To see or understand a difference between two things Discernible
Being an indispensable part of a whole Integral
complete set of patient information Medical record
Results of an exam Medical Report
Define objective Perceptible to the observer
An inference from what has been seen or heard Observation
Competency as a result of training & experience Proficiency
Records of patient visits, phone calls, progress & treatment that are inserted into the patients chart Progress notes
objective evidence of disease discoverable by dr. Sign
Fings perceptible only by the effected person Subjective
Any perceptible change in the body or its functions Symptom
Created by: spawmary