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bonewit chapter 1
The Medical Record
| Question | Answer |
|---|---|
| the physician responsible for the care of a hospitalized patient. | attending physician |
| the process of making written enteries 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 attendng 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 breif 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) |
| occuring 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 patients home or place of residence. | home health care |
| consent given by a patient for a medical procedure after being informed | 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 for impressions include provisional diagnosis and tentative diagnosis. | medical impression |
| a written record of the important information regarding a patient, including the care of that individual and the progress of the patient's condition. | medical record |
| the way a medical is organized. the two main type of medical record formats are source-oriented record and the problem-oriented record. | medical record format |
| a sympton that can be observed by an examiner | objective sympton |
| a medical record in paper form. | paper-based patient record(PPR) |
| an individual recieving medical care | patient |
| an assessment of each part of the patient's body to obtain objective data about the patient that assists in dtermining 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 and outcome of a disease and the prospects for a patient's recovery | prognosis |
| arranging documents with the most recent document on the top orin the front, which means that the oldest document is on the bottom or at the back of a section or file. | reverse chronological order |
| the method of organization for recording progress notes. the SOAP format includes the following categories:subjective data, objective data, assessment, and plan. | SOAP format |
| a symptom that is felt by the patient, but is not observable by an examiner. | subjective symptom |
| any change in the body or it's functioning that indicates the presence of disease. | symptom |
Created by:
sashapalmer
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