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Bonewit Chapter 1

The Medical Record

QuestionAnswer
The physician responsible for the care of a hospitalizedbpatient. Attending physician
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 that 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, or treatment of a patient's condition.
Discharge summary report A brief summary of the significant events of a patient's hospitalization.
Eletronic medical record (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.
Home health care The provision of medical and non-medical care in a patient's home or place of residence.
Informed consent Consent given by a patient for a medical procedure after being informed of the nature of his or her condition.
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
Medical record format The way a medical record is organized.
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 patients body.
Physical examination report A report of the objective findings from the physician'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 resent at the front and oldest in the back.
SOAP format A method of organization for recording progress notes; Subjective data, Objective data, Assessment, & 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 od disease.
Created by: justineentingh
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