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Bonewit Chapter 1

The Medical Record

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