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Bonewit Chapter1
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 Practitioner other than the attending physician. |
| Diagnosis | The scientific plan method of determining and identifying a patient's condition. |
| Diagnostic procedures | A procedure to preformed to assist in the diagnosis, management, or treatment of a patient's condition. |
| Discharge summary report | A brief summary of a significant events of a patient's hospitalization. |
| Electronic 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, including the care of the individual and the progress of the patient's condition. |
| Medical record format | The way a medical record is organized. the two main types of medical records formats are the source-oriented record and the problem-oriented record. |
| Objective symptoms | A symptom that can be observed by an examiner. |
| Paper-based patient record (PPR) | A medical record in paper form. |
| Patient | An individual who is receiving medical care. |
| Physical examination | An assessment of each part of the patients body to obtain objective data about the patients that assist in determining the patients state of health. |
| Physical examination report | A report of the objective findings from the physician assessment of each body system. |
| Problem | Any condition that requires further observation diagnosis, management, or patient education. |
| Prognosis | The probable course of and out come of a disease and the prospects for a patients recovery. |
| Reverse Chronological order | older documents on the bottom of the folder. |
| SOAP format | Subjective data, Objective data,Assessment, and plan. |
| Subjective plan | A symptom that is felt by the patient, but is not observable by an examiner. |
| Symptom | Any change in the body or it's functioning that indicates the presence of disease. |
Created by:
RyanBreakall
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