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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 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.
Created by: justine whitley