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Bonewit Chapter 1
The Medical Record
| Question | Answer |
|---|---|
| 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
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