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Bonewit Chapter 1
The Medical Record
| Question | Answer |
|---|---|
| Attending physician | The physician responsible for the care of a hospitalized patient. |
| Charting | The process of making written entries about a patient in the medical record. |
| Consultation report | A narrative 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 condition. |
| Diagnostic procedure | A procedure performed to assist in the diagnosis, management, and treatment of a patient's condition. |
| Discharge summary report | A brief summary of the significant events of a patient's hospitalization. |
| Electronic medical records (EMR) | A medical record that is stored on a computer. |
| Familial | Occurring 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. |
| Informed consent | Consent given to the patient regarding the purpose of the procedure, an explanation of risks involved, alternative treatments, the likely outcome, and the risks in delaying the procedure. |
| Inpatient | A patient who has been admitted to a hospital for at least one overnight stay. |
| Medical impressions | Conclusions drawn by the physician from an interpretation of data. |
| Medical record | 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 format | The way the medical record is organized. The two main types of formats are the source-oriented and the problem-oriented record. |
| Objective symptom | A symptom that can be observed by an examiner. |
| Paper-based patient record (PPR) | A medical record in paper form. |
| Patient | An individual receiving medical care. |
| Physical examination | 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 report | A report of the objective findings from the patient's assessment of each body system. |
| Problem | Any condition that requires further observation, diagnosis, management, or patient education. |
| Prognosis | The probable course and outcome of a disease and the prospects for a patient's recovery. |
| Reverse chronological order | Arranging documents with the most recent documents on top or in the front, which means that the oldest document is on the bottom or at the bottom of the file. |
| SOAP format | A method of organization for recording progress notes. The SOAP format includes the categories: subjective data, objective data, assessment, and plan. |
| Subjective symptom | A symptom that is felt by the patient, but is not observable by an examiner. |
| Symptom | Any change in the body or its functioning that indicates the presence of disease. |
| Home health care | The provision of medical and non-medical care in a patient's home or place of residence. |
Created by:
hannahbirt
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