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Bonewit Ch. 1
| 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 diagnosis, management, and treatment of a patient's condition. | Diagnosis Procedure |
| A brief statement 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 non-medical 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 his or her condition. | 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. | Medical Impressions |
| A written record of the important information regarding a patient, including the care of the patient and the progress of the patient's condition. | Medical Record |
| The way a medical record is organized.The 2 main types of medical record format are the source-oriented record and the problem-oriented record. | Medical Record Format |
| A symptom that can be observed by an examiner. | Objective Symptom |
| A medical record in paper form. | Paper Based Patient Record (PPR) |
| An individual receiving medical care. | Patient |
| An assessment of each part of a 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 patient condition that requires further observation, diagnosis, management, or patient education. | Problem |
| The probable course and outcome of a patient's condition and the patient's prospects for a recovery. | Prognosis |
| Arrangement of documents with the most recent document on top or in the front, which means that the oldest document is on the bottom or at the back of a section or file. | Reverse Chronological Order |
| A method of organization for recording progress notes. The SOAP format includes the following categories:subjective data, objective data, assessment, and plan. | SOAP |
| A symptom that is felt by a patient but is not observable by an examiner. | Subjective Symptom |
| Any change in the body or it's functioning that indicates that a disease might be present. | Symptom |
Created by:
brittanybenning
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