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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 writen entries about a patient in the medical record. |
| Diagnosis | The scientific method of determining and identifying a patient's condition. |
| Diagnostic procedure | A procedure performed to assist the diagnosis,management,or treatment of a patients condition. |
| Discharge summary report | A breif summary of the significant events of a patient's hospitalization. |
| Electronic Medical Record | 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 resdience. |
| Inpatient | A patient who has been admitted to a hospital for at least one over night 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 a medical record is organized.The |
| Object symptom | A symptom that can be observed by an examiner. |
| Paper based records | Medical record in paper form. |
| Patient | an individual recieving medical care. |
| Physical examination | An assesment of each part if 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 physician's assesment 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 document on top or in the front which means that the oldest document is on the botttom or at the back of a section or file. |
| SOAP format | A method of organization for recording progress notes. Subjective,objective,assesment,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. |
| Informed consent | Consent given by a patient for a medical procedure after being informed of the nature of his or her condition,the purpose of the procedure,an explanation of the risks involved with the procedure,alternative treatments or procedure avalible,the likely |
| outcome of the procedure,and the risks involved with declining or delaying the procedure. | |
| suspension | |
Created by:
justine whitley
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