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chapter 2 flash card

flash cards2

TermDefinition
chief complaint main reason for a patients visit
"pre-op" before surgery
radiology report explains the reason for ordering a radiologic image, how the image was performed, what was seen on the image, and the reviewing radiologist's assessment
"ER" emergency room
discharge summery note a note that details when and why a patient was admitted
the only note that DOES NOT follow the SOAP format prescription
admission summary documents the admission of a patient to the hospital
"L&D" labor and delivery
"febrile" to have a fever
"EHR" electronic health records
Created by: shannapie
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