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Introduction to Health Records

QuestionAnswer
The information contained in a patient's records that serves as a roadmap to his or her health history detailing previous illnesses and treatment. Electronic Health Record (EHR)
A decrease in level consciousness; in a medical record, this is generally an indication that the patient is really sick. lethargic
It just started recently or is a sharp, severe symptom Acute
diseased tissue lesion
preventive treatment prophylaxis
Out to the side lateral
It has been going on for a while chronic
Comprise the patient's physical exam, any laboratory findings, and imaging studies performed at the visit. Objective data
it runs in the family genetic / hereditary
Being aware of who he or she is, where he or she is, and the current time; a person who is aware of all three is oriented
Created by: JLBibbs0317
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