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Key Terms

Chapter 1

TermDefinition
Diagnosis The scientific method of determining and identifying a patient's condition
Diagnostic procedure A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition
Documenting The process of recording information about a patient in the medical record
Electronic medical record (EMR) A medical record that is stored on the computer
Familial disease (family) A condition that occurs in or affects blood relatives more frequently than would be expected by chance
Health history report A collection of subjective data about a patient
Medical record A written record of important information regarding a patient, including the care of that individual and the progress of the patient's condition
Objective symptom A symptom that can be observed by an examiner
Paper-based patient record (PPR) A medical record in paper form
Subjective symptom A symptom that is felt by the patient but is not observable by an examiner
Symptom Any change in the body or it's functioning that indicates the presence of disease
Created by: Tangeladenise
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