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Bonewit #1 (8th Ed)
The Medical Record - Mrs. Marshall
| Question | Answer |
|---|---|
| The physician responsible for the care of a hospitalized patient. | Attending Physician |
| The process of making written entries about a patient in the medical record. | Charting |
| A narrative report of an opinion about a patient's condition by a practitioner other than the attending physician. | Consultation report |
| The scientific method of determining and identifying a patient's condition. | Diagnosis |
| A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition. | Diagnostic procedure |
| A brief summary of the significant events of a patient's hospitalization. | Discharge summary report |
| A medical record that is stored on a computer. | Electronic medical record (EMR) |
| Occurring or affecting members of a family more frequently than would be expected by chance. | Familial |
| A collection of subjective data about a patient. | Health history report |
| The provision of medical and nonmedical care in a patient's home or place of residence. | Home health care |
| Consent given by a patient for a medical procedure after being informed of the nature of their condition, the purpose & any risk of the procedure; alternative treatments or procedures; the likely outcome & the risk of declining or delaying the procedure. | Informed consent |
| A patient who has been admitted to a hospital for at least one overnight stay. | Inpatient |
| Conclusions drawn by the physician from an interpretation of data. Other terms include provisional diagnosis and tentative diagnosis. | Medical impressions |
| A written record of the important information regarding a patient, including the care of the individual & the progress of the patient's condition. | Medical record |
| The way a medical record is organized. The two main types are the source-oriented record & the problem-oriented record. | Medical record format |
| A symptom that can be observed by the examiner. | Objective symptom |
| A medical record that is paper form. | Paper-based patient record (PPR) |
| An individual receiving medical care. | Patient |
| An assessment of each part of the patient's body to obtain objective data about the patient that assists in determining the patient's state of health. | Physical examination |
| A report of the objective findings from the physician's assessment of each body system. | Physical examination report |
| Any condition that requires further observation, diagnosis, management, or patient education. | Problem |
| The probable course & outcome of a disease & the prospects for a patient's recovery. | Prognosis |
| Arranging documents with the most recent document on top or in front, which means that the oldest document is on the bottom or at the back of a section or file. | Reverse chronological order |
| method of organization for recording progress notes & includes the following categories: subjective data, objective data, assessment & plan. | SOAP format |
| A symptom that is felt by the patient but is not observed by the examiner. | Subjective data |
| Any change in the body or its functioning that indicate the presence of disease. | Symptom |
Created by:
Mrs.Marshall
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