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Bonewit chapter 1
The medical record
| Question | Answer |
|---|---|
| Attending physician | the physician resondible for the care of a hospitalized patient |
| Charting | the process of making written entries baout a patient in the medical record |
| Consultation report | a narritive report of an opinion about a patient's condition by a practitioner other than the attending physician |
| Diagnosis | the scientific method of determining and identifying a patient's comdition |
| Diagnostic procedure | a procedure performed to assist in the diagnosis,management,ot treatment of a patient's condition |
| Discharge summary report | a brief summary of the significant events of a patient's hospitalization |
| Electronic medical record | a medical record that is stored on a computer |
| Familial | occuring or affecting members 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 concent | the concent given by a pateint for medical procedure after being informed of the procedure |
| Inpatient | a patient who has been admitted to the hospitlal fot at least one overnight stay |
| Medical impressions | the conclusions reached by a physician from an inturpritation of data |
| Medical record | a written record of the important information regaurding a patient |
| Medical record format | the way in wich a medical record is organized. the two main ways are:source-oriented and problem-oriented |
| Objective symptom | a symptom that can not be observed by examiner |
| Patient | an individual receiving medical care |
| Paper-based patient record (PPR) | a medical record on paper |
| physical examination | assesment of each part of the patient's body to obtain objective data |
| physical examination report | a report of the objective findings from the physician's assesment of each body system |
| Problem | any condition that requires futher observations,diagnosis,management,or patient education |
| Prognosis | the probable course and outcome of a disease and the prospect for recovery |
| Reverse chronological order | arrainging documents with the most recent document on top or in front |
| SOAP format | organization of recording notes;S-subjective data,O-objective data,A-assesment,and P-plan |
| Subjective symptom | a symptom felt by the patient but not observed by an examiner |
| Symptom | any changr in the body or its functioning indicative that a disease is present |
Created by:
AnnaJoseph
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