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Bonewit Chapter 1

The Medical Record

The physician responsible for the care of 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 the diagnosis, management, or treatment of a patient's condition. Diagnostic procedure
A brief summary of the significant events of a patient's hospitalization. Discharge summary report.
A medical record that is stored on a computer Electronic medial 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 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 conditions 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 that individual and the progress of the patient's condition Medical record
The way a medical record organized. The two main types of medical record formats 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 the 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 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 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 format
A symptom that is felt by the patient, but is not observable by an examiner Subjective symptom
Any change in the body or its functioning that indicates the presence of disease Symptom
Created by: ReganEntler