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Medical Record

Attending Physician The physician responsible for the care of a hospitalized patient.
Charting The process of making written entries about a patient in the medical record.
Consultation Report A narrative report of an opinion about a patient's condition by a pracitioner other than the attending physician.
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.
Discharge Summary Report A brief summary of the significant events of a patient's hospitalization.
Electronic Medical Record (EMR) A medical record that is stored on a computer.
Familial Occurring or affecting memers of a family more frequently than would be expected by chance.
Health History Report A collection of subjective data about a patient.
Home Health Care The provision of medical and non-medical care in a patient's home or place of residence.
Informed Consent The consent given by a patient for a medical procedure after being informed of the procedure.
Inpatient A patient who has been admitted to a hospitial for at least one overnight stay.
Medical Impressions Conclusions drawn by the physician from interprettion of data.
Medical Record A written record of the important information regarding a patient.
Medical Record Format The way a medical record is organized.
Objective Symptom A symptom that can be observed by an examiner.
Paper-Based Patient Record (PPR) A medical Record in paper form.
Patient An individual receiving medical care.
Physical Examination An assessment of each part of the patients body to obtain objective data about the patient that assists determining the patients state of health.
Physical Examination Report A report of the objective findings from the physicians assessment of each body system.
Problem Any condition that requires further observation, diagnosis, management, or patient education.
Prognosis The probable course and outcome of a disease and the prospects for a patients recovery.
Reverse Chronological Order Arranging documents with the most recent document on the top or in the front, which that means the oldest document is on the bottom or at the back of a section.
SOAP Format A method of organization for recording progress notes.
Subjective Symptom A symptom that is felt by the patient, but is not observable by an examiner.
Symptom Any change in the body or its functioning that indicates the presence of disease.
Created by: brittanycaupp