Busy. Please wait.

show password
Forgot Password?

Don't have an account?  Sign up 

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
We do not share your email address with others. It is only used to allow you to reset your password. For details read our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

Remove Ads
Don't know
remaining cards
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
restart all cards

Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

Bonewit chapter 1

The medical record

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